Provider's Request for Adjustment

Document Information
  How to complete a fillable form.
Title Provider's Request for Adjustment

Providers use this to report total overpayment, partial overpayment and/or underpayment by L&I.

Document number F245-183-000
How to get this document
Alt Language(s)
Valid dates 01/2014, 11/2013
Contact information Managing Injured Workers' Claims
Websites For Medical Providers

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