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Provider Credentialing 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.



Form
F245-365-000


 
Statewide Payee Registration and W-9 Form

Use this form to register or update your taxpayer ID number or register and make changes to your direct deposit information.



Form
F248-036-000


 





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