Get a Form or Publication: Provider Credentialing

Your search for "Provider Credentialing" returned 2 documents.

Title Type Number
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 submit your taxpayer ID number. Note: Register now for direct deposit available at a later date.

 Form F248-036-000



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