Provider Payment Account Change Form

Document Information
  How to complete a fillable form.
Title Provider Payment Account Change Form

Providers use this form to notify L&I of a change of their business address, billing address and account termination. Also has info on how to notify L&I on a tax ID (EIN) number change, tax ID address change and/or name change.

Document number F245-365-000
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  • Alt Language(s)
    Valid dates 04/2015
    Contact information Provider Feedback
    Websites For Medical Providers

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