Providers Request for Adjustment
See also
| Document Information | ||
|---|---|---|
 Get help downloading & printing files.  How to complete a fillable form. |
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| Title |
Providers Request for Adjustment (A fillable form - 278 KB PDF)
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| Description | Providers use this to report total overpayment, partial overpayment and/or underpayment by L&I. These forms will be accepted by L&I. They may not be accepted by all Medical Bill Processors due to lack of a barcode. |
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| Detail | ||
| Form number | F245-183-000 | |
| Availability | Order it |
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| Keywords | adjustment form, adjustments, billing errors, bills, medical services, most requested forms, provider | |
| Languages | English | |
| Valid dates | 04-2010 | |
| Contact information |
Managing Injured Workers' Claims
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| Web pages | For Medical Providers | |
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