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Account Deposit for Factory Assembled Structures Account Holders

You must have a contractor license number or have completed an application for a miscellaneous account to use this form.



Form
F622-081-000


 
Affidavit of Continuity Medical Gas Installation

Affidavit of Continuity



Form
F627-043-000


 
Application for Insignia Conversion Vendor/Medical Units

Used to apply for an official insignia for conversion vendor or medical unit factory-assembled structures. See sample form for instructions about how to fill out the form correctly.



Form
F623-021-000


 
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


 
Application for LEP Compensation Medical / Solicitud para Compensación por Reducción de Ingresos (Médicos) (English/Spanish)

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

Este formulario completo no es una garantía para recibir beneficios.  Los pagos de beneficios lo decidirá su gerente de reclamo.



Form
F242-208-909



Alt Language(s):
Inglés
Español
 
Application for Loss of Earning Power (LEP) - Compensation Medical

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.



Form
F242-208-000



Alt Language(s):
English/Español
Español
 
Application to Establish an Factory Assembled Structure Deposit Account with the Dept. of Labor and Industries

Use to establish a factory assembled structure (FAS) deposit account. FAS deposit accounts are for businesses or other entities that are not currently licensed or registered with L&I as electrical or construction contractors but are legally required to purchase work permits from L&I. (3 pgs)



Form
F120-116-000


 
Comentarios Sobre el Exámen Médico Independente

Usado por el trabajador lesionado para proporcionarle comentarios a L&I sobre su examen médico reciente de un Examen Médico Independiente (IME, por su sigla en inglés).



Form
F245-053-999



Alt Language(s):
Inglés
 
Comentarios Sobre el Exámen Médico Independente

Usado por el trabajador lesionado para proporcionarle comentarios a L&I sobre su examen médico reciente de un Examen Médico Independiente (IME, por su sigla en inglés).



Form
F245-053-999



Alt Language(s):
Inglés
 
Continuación del Historial de Trabajo y de Enfermedad Ocupacional

El trabajador lesionado llena este formulario para documentar una posible enfermedad ocupacional y para mostrar su historia de trabajo.



Form
F242-071-911



Alt Language(s):
Inglés
 
Crime Victims Statement for Home Nursing Services

Used by the Crime Victims Compensation Program providers for reimbursement of home nursing services. Crime Victims Compensation Program providers are required to bill using this form.



Form
F800-070-000


 
Crime Victims Statement for Pharmacy Services

Used by Crime Victims Compensation Program providers to bill for pharmacy services. Crime Victims Compensation Program providers are required to bill using this form.



Form
F800-058-000


 
Crime Victims Statement for Pharmacy Services

Used by Crime Victims Compensation Program providers to bill for pharmacy services. Crime Victims Compensation Program providers are required to bill using this form.



Form
F800-058-000


 
Heat-related Illness Education Card/Tarjeta de Educación sobre Enfermedades Relacionadas con el Calor (English/Spanish)

Identifies the effects of heat exhaustion and heat stroke on the body and what to do if you observe symptoms. Reviews prevention steps. PDF file is set up for two copies to print at one time.

Identifica los efectos del agotamiento por el calor y la insolación en el cuerpo y lo que puede hacer si observa estos síntomas. Revisa los pasos para la prevención.  El archivo PDF está configurado para que se impriman dos copias al mismo tiempo.



Publication
F417-218-909


 
Historial de Trabajo (Enfermedad Ocupacional)

El trabajador lesionado llena este documento para presentar su historia de trabajo.  El formulario de continuación a esta página es F242-071-911.



Form
F242-071-999



Alt Language(s):
Inglés
Español
 
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


 
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


 
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


 
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


 
Insurer Activity Prescription Form

Used by health-care providers to communicate an injured worker's status, physical capacities, inability to work (time-loss) and treatment plans. To print an APF, click on the title of the form in the box above.



Form
F242-385-000



Alt Language(s):
English/Español
 
Logging Emergency Medical Plan (Logging Safety and Health Meetings)

Use this two part form for employers to record work locations and emergency rescue info and for holding safety meetings for each new jobsite



Form
F417-014-000


 
Medical Device Review Request

This form is so L&I's Office of the Medical Director can evaluate medical device(s) that the attending physican wants to use to treat an injured worker.



Form
F252-013-000


 
Medical Device Review Request

This form is so L&I's Office of the Medical Director can evaluate medical device(s) that the attending physican wants to use to treat an injured worker.



Form
F252-013-000


 
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. Find a medical examiner.



Publication
F252-001-000


 
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. Find a medical examiner.



Publication
F252-001-000


 
Need a Doctor?

Information card: Provides contact information for injured workers needing assistance in finding a health-care provider who will treat their occupational injury or disease. This PDF will print out an 8.5" X 11" sheet that has 12 copies of the card. Note: Disclaimer information on Page 2 may not line up accurately in two-sided printing.



Publication
F160-006-000



Alt Language(s):
Español
 
Need a Doctor?

Information card: Provides contact information for injured workers needing assistance in finding a health-care provider who will treat their occupational injury or disease. This PDF will print out an 8.5" X 11" sheet that has 12 copies of the card. Note: Disclaimer information on Page 2 may not line up accurately in two-sided printing.



Publication
F160-006-000



Alt Language(s):
Español
 
Non-Network Provider Application

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 www.ProviderNetwork.Lni.wa.gov



Form
F248-011-000


 
Occupational Disease & Employment History

Injured worker fills this out to document possible occupational disease and to show work history.



Form
F242-071-000



Alt Language(s):
Español
 
Occupational Disease Work History - Continuation

This is a continuation page to the Occupational Disease Work History (F242-071-000) to add additional work history.



Form
F242-071-111



Alt Language(s):
Español
 
Out of Country Provider Application

This application is for providers outside the United States. Providers who treat injured workers must have a provider number to bill the department.



Form
F248-361-000



Alt Language(s):
Español
 
Plumber, Medical Gas, or Trainee Renewal

This form is used to renew a plumber certification, plumber trainee or medical gas installer certification.



Form
F627-019-000


 
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


 
Provider's Initial Report (PIR)

Used by medical providers when reporting initial treatment for an industrial injury or occupational disease for a self-insured claim. The paper version dated 10-2012 is still valid, as is the 01-2014 word fillable version.

Medical providers treating self-insured workers, self-insured businesses, or their third party claims administrators can access this form one of two ways:

  1. Download the Microsoft (MS) Word form and the PDF file with instructions:

           The first file is the PDF instructions.

           The second file is an Office 2003 MSWord document ending in .doc.

           The third file is an Office 2007/2010 version, ending in .docx.

2.  Order paper copies of this form by clicking the “order it” button.



Form
F207-028-000


 
Provider's Initial Report (PIR)

Used by medical providers when reporting initial treatment for an industrial injury or occupational disease for a self-insured claim. The paper version dated 10-2012 is still valid, as is the 01-2014 word fillable version.

Medical providers treating self-insured workers, self-insured businesses, or their third party claims administrators can access this form one of two ways:

  1. Download the Microsoft (MS) Word form and the PDF file with instructions:

           The first file is the PDF instructions.

           The second file is an Office 2003 MSWord document ending in .doc.

           The third file is an Office 2007/2010 version, ending in .docx.

2.  Order paper copies of this form by clicking the “order it” button.



Form
F207-028-000


 
Provider's Request for Adjustment

Providers use this to report total overpayment, partial overpayment and/or underpayment by L&I.



Form
F245-183-000


 
Report of Accident (ROA) Workplace Injury, Accident or Occupational Disease

This form is not available to download. If you are an injured worker, ask your medical provider for a copy of this form or you can complete your portion of the Report of Accident (ROA) online at https://secure.Lni.wa.gov/home.

Please note only medical providers may order this form from the Warehouse.



Form
F242-130-000



Alt Language(s):
Español
 
Safety Standards for WAC 296-802, Employee Medical and Exposure Record

The purpose of this chapter is to provide employees and their designated representatives the right to access relevant medical and exposure records. It also describes the procedures WISHA will follow when accessing confidential medical information.



Manual
F414-122-000


 
Self-Insurance Medical Provider Billing Dispute form

A form for Providers to submit disputes to the department regarding payment of medical provider bills



Form
F207-207-000


 
Self-Insurance Medical Provider Billing Dispute form

A form for Providers to submit disputes to the department regarding payment of medical provider bills



Form
F207-207-000


 
Self-Insurance Medical Provider Billing Dispute form

A form for Providers to submit disputes to the department regarding payment of medical provider bills



Form
F207-207-000


 
Self-Insurer Accident Report (SIF-2)

Provided to workers by the self-insured businesses or their third party claims administrators to report an industrial injury or occupational disease. This form is not on the internet. If you are an injured worker, ask your employer for a copy of this form. Self-insured businesses or their third party claims administrators may order copies of this form. Cllick the "order It" button below to order paper copies or request the form in MSWord.



Form
F207-002-000


 
Solicitud para Compensación por Reducción de Ingresos (Médico)

Completando este formulario no es una garantía para recibir beneficios.  El pago de beneficios lo decidirá su gerente de reclamo.



Form
F242-208-999



Alt Language(s):
Inglés
English/Español
 
Su Examen Médico Independiente: Para empleadores de negocios autoasegurados

Panfleto: Contesta las preguntas más comunes sobre cuándo y por qué puede requerirse que un trabajador lesionado asista a un examen médico independiente.  Incluye el formulario, "Examen Médico Independiente (IME) Solicitud para el reembolso de gastos de viaje y salario." Esta publicación es para uso solamente de las empresas autoaseguradas y sus trabajadores.



Publication
F207-202-999



Alt Language(s):
Inglés
 
Su Examen Médico Independiente: Para empleadores de negocios autoasegurados

Panfleto: Contesta las preguntas más comunes sobre cuándo y por qué puede requerirse que un trabajador lesionado asista a un examen médico independiente.  Incluye el formulario, "Examen Médico Independiente (IME) Solicitud para el reembolso de gastos de viaje y salario." Esta publicación es para uso solamente de las empresas autoaseguradas y sus trabajadores.



Publication
F207-202-999



Alt Language(s):
Inglés
 
Tarjeta para Transferencia de Caso

Usada por los trabajadores lesionados para notificar al gerente de reclamo y solicitar autorización para transferir el cuidado a un doctor diferente.



Form
F245-037-999



Alt Language(s):
Inglés
 
Transfer of Care Card

Used by injured worker to notify claim manager and request authorization to transfer care to a different doctor. Do it online! Use the online Transfer of Care



Form
F245-037-000



Alt Language(s):
Español
 
Travel Reimbursement Request

Bill form for use by workers to request reimbursement for authorized travel expenses.



Form
F245-145-000



Alt Language(s):
Español
 
Vendor / Medical Conversion Units Pre-Inspection Checklist

Pre-Inspection Checklist to assist vendor owners, manufacturers, and others on what they need to know to get their vendor/medical unit approved by Labor and Industries.



Form
F622-072-000


 
Vocational Training Plan Ownership Agreement for Tools and Equipment

Injured worker agrees to the ownership terms of the tools and/or equipment purchased as part of their training plan by L&I.



Form
F245-351-000



Alt Language(s):
Español
 
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
 
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.



Publication
F245-224-000



Alt Language(s):
Español
 
Approved Independent Medical Examiner (IME) Update
To update or correct the IME's contact, availability, qualificaitons and/or exam sites.

Form
F245-051-000


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

Form
F245-051-000


 
Attending Provider's Return-to-Work Desk Reference
Book: Discusses best practices in occupational medicine that help return an injured worker to his/her job as soon as medically possible. Identifies resources available from L&I and explains how to bill for return-to-work services. Three hours of Category 1 CME credit are offered for completing an online self-assessment. Go to www.CMECredits.Lni.wa.gov.

Publication
F200-002-000


 
CMS 1500 (formerly L&I Health Insurance Claim form)
Used by providers to be reimbursed for services. It is NOT for use by injured workers to submit a claim to L&I.

Form
F245-127-000


 
CMS 1500 (formerly L&I Health Insurance Claim form)
Used by providers to be reimbursed for services. It is NOT for use by injured workers to submit a claim to L&I.

Form
F245-127-000


 
Facts about Medical Gas Piping Installer Endorsement
Fact sheet: Explains training requirements and the endorsement process for medical gas piping installers.

Publication
F627-026-000


 
Hotline Tips for Medical Services Providers
Fact sheet: Provides tips to help medical service providers quickly obtain answers to claims and billing questions. Introduces L&I's Provider Hotline, Interactive Voice Response Message System and online Claim & Account Center.

Publication
F248-040-000


 
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


 
Independent Medical Exam Template
Template used by a doctor during an independent medical exam.

Form
F245-058-000


 
Independent Medical Examination Fax Cover Sheet
Independent Medical Examination Fax Cover Sheet

Form
F245-383-000


 
Independent Medical Examination Fax Cover Sheet
Independent Medical Examination Fax Cover Sheet

Form
F245-383-000


 
Medical Payment Guidance

Flyer: Describes how a payment for health-care services is mailed separately from the explanation for the payment (the remittance advice). An illustration explains how to link a payment with its explanation. Also includes information about how providers can always find their remittance advices online through L&I's Provider Express Billing.



Publication
F248-366-000


 
Notice of Independent Medical Exam No-Show or Late Cancellation
Notice of Independent Medical Exam No-Show or Late Cancellation

Form
F245-382-000


 
Notice of Independent Medical Exam No-Show or Late Cancellation
Notice of Independent Medical Exam No-Show or Late Cancellation

Form
F245-382-000


 
Provider Network Agreement
The provider network agreement for participation in the health care provider network for injured workers covered by Washington State Fund and self-insured employers.

Form
F245-397-000


 
RCW 43.22.380 Exemptions Fire and Safety Checklist for Vendor/Medical Conversion Units
Generic Checklist to determine if the particular installation includes all requirements prior to calling for an inspection. Must be able to answer YES to all questions prior to calling.

Form
F622-073-000


 
Taxi-for-hire Vehicle Reporting Requirements
Fact sheet: Provides information for the for-hire industry about mandatory coverage for all for-hire drivers. Includes the different reporting methods and due dates of quarterly reports.

Publication
F212-245-000


 
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


 
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
 





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