Provider's Request for Adjustment

Provider''s Request for Adjustment - (Forms/Publications)
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Title Provider''s Request for Adjustment (A fillable form - 174 KB PDF)

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

Form number F245-183-000
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Keywords adjustment form, adjustments, billing errors, bills, medical services, provider
Languages English
Valid dates 11-2013 , 01-2014
Contact information Managing Injured Workers' Claims
Web pages For Medical Providers

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