CMS 1500 (formerly L&I Health Insurance Claim form)
 

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Title CMS 1500 (formerly L&I Health Insurance Claim form) (A fillable form - 396 KB PDF)
Description Used by providers to be reimbursed for services. It is NOT for use by injured workers to submit a claim to L&I.
Detail
Form number F245-127-000
Availability Order it
Keywords medical, medical services, provider, reimbursement
Languages English
Valid dates 08-2005
Contact information Managing Injured Workers' Claims
Claims for Job Injuries
Web pages For Medical Provider

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