Provider Account Application


Provider Account Application

Document Information
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Title	Provider Account Application (A fillable form - 426 KB PDF)
Description	For providers to apply for a provider account number with L&I. Includes the Form W-9 Request for Taxpayer ID Number and Certification (F248-036-000). 10-2009 version is internet only, not printed.
Detail
Form number	F248-011-000
Availability	Order it
Keywords	application, crime, crime victim, crime victim provider, doctor, interpreter, medical provider, most requested forms, physician, physician assistant, provider, provider application
Languages	English
Valid dates	10-2009, 05-2009
Contact information
Web pages	For Medical Providers