Non-Network Provider Application

Non-Network Provider Application - (Forms/Publications)
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Title Non-Network Provider Application (A fillable form - 525 KB PDF)

Includes the F248-036-000 Statewide Payee Registration and W-9 form. For providers to complete that do not want to become a Labor and Industries network provider, or for a specialty that L&I is not accepting network applications for at this time. If you are applying to be a Labor and Industries network provider, please complete application process at

Form number F248-011-000
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Keywords crime victim provider, doctor, interpreter, medical provider, physician assistant, provider application
Languages English
Valid dates 01-2013
Contact information
Web pages For Medical Providers

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