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Your Independent Medical Exam: For Employees of Self-Insured Businesses
Pamphlet: Answers the most common questions about when and why an injured worker may be required to attend an independent medical exam. Includes the "IME Travel & Wage Reimbursement Request" form. This publication is for use only by self-insured businesses and their workers.

Publication
F207-202-000

Alt Language(s):
Español
 
Your Independent Medical Exam: For Employees of Self-Insured Businesses - Spanish (Su Examen Médico Independiente: Para empleadores de negocios autoasegurados)
Pamphlet: Answers the most common questions about when and why an injured worker may be required to attend an independent medical exam. Includes the "IME Travel & Wage Reimbursement Request" form. This publication is for use only by self-insured businesses and their workers.

Publication
F207-202-999

Alt Language(s):
Inglés
 
Independent Medical Exam Doctor's Estimate of Physical Capacities

IME Doctor’s Estimate of Physical Capacities: For use by independent examiners when asked to estimate physical capacities as part of an IME requested by the department.



Form
F242-387-000
 
Provider Account Application - Independent Medical Examiner (IME)

In order to do independent medical exams a provider must obtain a provider account number with L&I. This packet includes the application and agreement with instructions, IME Provider Exam sites form (F245-047-000) and Request for Taxpayer ID and Certification - Form W-9 (F248-036-000) (10 pages). If you have questions, please email balk235@lni.wa.gov or call 360-902-6815.



Form
F245-046-000
 
Independent Medical Examination (IME) Provider Exam Sites

List the locations where the doctor does independent medical exams on a regular basis.



Form
F245-047-000
 
Approved Independent Medical Examiner (IME) Update
To update or correct the IME's contact, availability, qualificaitons and/or exam sites.

Form
F245-051-000
 
Independent Medical Exam Comments
Used by the injured worker to provide comments to L&I about their recent medical exam by an IME.

Form
F245-053-000

Alt Language(s):
Español
 
Independent Medical Exam Template
Template used by a doctor during an independent medical exam.

Form
F245-058-000
 
Your Independent Medical Exam

Pamphlet/booklet: Answers the most common questions about independent medical exams and when and why an injured worker may be required to receive one. Includes the "IME Travel & Wage Reimbursement Request" form.



Form
F245-224-000

Alt Language(s):
Español
 
Su Examen Médico Independiente

Panfleto/folleto: Respuestas a las preguntas más comunes sobre los exámenes médicos independientes y cuándo y por qué podría requerirse que un trabajador lesionado asistiera a uno.  Incluye el formulario “Examen Médico Independiente (IME) - Solicitud para el reembolso de gastos de viaje y salario.” Este formulario es solamente para el uso de negocios autoasegurados y sus trabajadores.



Form
F245-224-999

Alt Language(s):
Inglés
 
Notice of Independent Medical Exam No-Show or Late Cancellation
Notice of Independent Medical Exam No-Show or Late Cancellation

Form
F245-382-000
 
Independent Medical Examination Fax Cover Sheet
Independent Medical Examination Fax Cover Sheet

Form
F245-383-000
 
Medical Examiners' Handbook

Book: A publication for independent medical examiners, attending doctors and consultants, this document contains guidelines, sample reports and billing procedures for preparing and conducting impairment ratings and independent medical exams in Washington's workers' compensation system. Beginning July 1, 2012, free Category I CME credits are available for completing the self-assessment associated with this handbook. Go to www.Imes.Lni.wa.gov and click on Medical Examiners Handbook for information on the exam. L&I and the authors have no financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this document.



Publication
F252-001-000
 
Notice of Deficiencies (Crane/Derrick Certification Examination)
Use this form for noting any deficiencies of cranes, derricks, material handling devices, spouts, suckers and similar equipment.

Form
F416-054-000
 
Physical Exam - Charter Boat Operators License

This form is used by applicants applying for a charter boat operators license to have completed by a physician for an operators license



Form
F416-056-000
 
Application for Master Electrician Certification Examination

Use this form to apply for the master electrician exam.



Form
F500-088-000
 
Application for a 0% Supervision Modified Electrical Training Certificate & Specialty Examination

Covers 03A, 06B, 07A, 07B, 07C, 07D, 07E, and 10 specialty licenses.



Form
F500-097-000
 
Application for Electrician Examination

Application and instructions for a Washington State electrician's certificate examination.



Form
F626-001-000
 
Application for Plumber Examination, Reciprocal, Medical Gas Endorsement, or Temporary Permit

This form is used to apply for plumber examination, reciprocal and medical gas endorsement.



Form
F627-008-000
 
Plumbers Examination Dates and Locations

The 2014 Plumber Examination Dates and Locations. A printed version is also available from the L&I Warehouse.



Form
F627-027-000
 
Application for Backflow Specialty Exam

This form is used to apply for the backflow specialty examination.



Form
F627-035-000
 
Crime Victim Compensation Program Sexual Assault Exam Report

A form used by physicians, hospitals and clinics to provide information and reporting to the Crime Victims Compensation Program.



Form
F800-098-000
 
Billing Guidelines for Sexual Assault Examinations: Crime Victims Compensation Program

Provides information health-care providers need to bill the Crime Victims Compensation Program for medical services.



Manual
F800-100-000
 
Your Independent Medical Exam (IME): Crime Victims Compensation Program
Fact Sheet: Provides answers to commonly asked questions about independent medical exams (IMEs) and contact information. Includes a form for requesting travel-related reimbursement for attending an IME.

Publication
F800-115-000
 
Application for Apprenticeship

EXAMPLE ONLY: Example of an application to apply for an apprenticeship. Registered Apprenticeship Programs use their own forms. NOT TO BE USED TO REQUEST PLUMBER or ELECTRICAL TRAINEE CARD.



Form
F100-033-000
 
Apprenticeship Applicant Register
Example: Used for tracking applicants for an apprenticeship program. Registered Apprenticeship Programs use their own forms.

Form
F100-045-000
 
Comentarios Sobre el Exámen Médico Independente
Used by the injured worker to provide comments to L&I about their recent medical exam by an IME.

Form
F245-053-999

Alt Language(s):
Inglés
 
L&I Chiropractic Consultant Application
This application is for doctors applying for second opinion examiner (consultant) status. Current consultants do not need to reapply.

Form
F245-393-000
 
Application for Certificate of Competency as an Inspector of Pressure Retaining Items
To apply for a certificate of competency as an Inspector of Pressure Retaining items. You can only mail or fax this form to L&I. Emailed forms are not accepted. NOTE: Applications MUST be received no later than 30 days prior to the exam date. Incomplete applications WILL NOT be accepted.

Form
F620-040-000
 
Roof Affidavit and Structural Inspection Request

The purpose of the manufactured home roof affidavit is to provide timely inspections and communications between the contractor and/or owner and FAS inspectors and field staff.

A structural inspection request questionnaire will not be required when a roof change out occurs if no structural changes are made in the roof sub-surface and roof cavity. Example: Repairing or replacing the roof trusses, rafters, ridge beam and the replacement of not more than (4) 4’x 8’ of roof sheathing.



Form
F622-076-000
 
Facts about State Certification for Plumbers
Fact sheet: Explains plumber classifications, certification requirements, including required exams, and the application and renewal processes, including continuing education requirements.

Publication
F627-022-000
 
Travel Reimbursement Request - Crime Victims
If you are considered a victim of crime, use this form to track your travel expenses for medical, retraining or vocational services or for an independent medical exam. You should have approval from your claim manager before you travel.

Form
F800-049-000
 
Sample Self-Employment Agreement

Sample of a letter a return to work person would use to assist L&I in determining whether services or funds should be authorized to assist them in becoming self-employed.



Form
F252-032-000
 
Application for Pump Installer Combination General Contractor Registration and Electrical Contractor License

Used for creating combination electrical and plumbing contractors license



Form
F500-104-000
 





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