Forms and Publications

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Title Number / Language
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3 Things to Know about L&I's Medical Provider Network  F242-406-000 (English)
 F242-406-999 (Spanish)
Activity Coaching Flyer for Providers  F280-062-000 (English)
Attending Provider's Referral Form  F252-098-000 (English)
Attending Provider's Return-to-Work Desk Reference  F200-002-000 (English)
Cholinesterase Monitoring Health Care Provider Recommendations  F413-070-000 (English)
 F413-070-999 (Spanish)
Crime Victims Provider's Request for Adjustment  F800-064-000 (English)
Elevator Continuing Education Provider / Instructor Application  F621-078-000 (English)
Firm Vocational Provider Account Change  F252-022-000 (English)
General Provider Billing Manual  F248-100-000 (English)
Hearing Aid Repair/Durable Medical Equipment Provider Hotline Service Authorization Request  F245-418-000 (English)
Helpful Tips for Medical Services Providers  F248-040-000 (English)
Helping Providers Understand the Crime Victims Compensation Program  F800-102-000 (English)
IME Provider Renewal Application  F245-435-000 (English)
Independent Medical Examination (IME) Provider Exam Sites  F245-047-000 (English)
Individual Vocational Provider Account Change Form  F252-021-000 (English)
L&I Medical Provider Network Credentialing Checklist  F245-445-000 (English)
Master Level Counselor Provider Account Application for Crime Victims  F800-053-000 (English)
Non-Accredited or Unlicensed Training Provider Application Supplemental Requirements  F280-045-000 (English)
Non-Network Provider Application  F248-011-000 (English)
Occupational Lead Exposure: An Alert for Health Care Providers  F310-005-000 (English)
On-The-Job Training (OJT) Agreement for Vocational Providers  F280-039-000 (English)
Out of Country Provider Application  F248-361-000 (English)
 F248-361-999 (Spanish)
Physical/Occupational/Massage Therapy Provider Hotline Service Authorization Request  F245-417-000 (English)
Provider Account Application - Independent Medical Examiner (IME)  F245-046-000 (English)
Provider Change Form for Crime Victims Compensation  F800-089-000 (English)
Provider General Billing Manual  F245-432-000 (English)
Provider Network Agreement  F245-397-000 (English)
Provider Payment Account Change Form  F245-365-000 (English)
Provider's Initial Report (PIR)  F207-028-000 (English)
Provider's Request for Adjustment  F245-183-000 (English)
Quick Reference Card for Providers 2015  F245-414-000_2015 (English)
Quick Reference Card for Providers 2016  F245-414-000_2016 (English)
Quick Reference Card for Providers 2017  F245-414-000_2017 (English)
Self-Insurance Medical Provider Billing Dispute Form  F207-207-000 (English)
Statewide Payee Registration for Provider Credentialing  F248-036-000 (English)
Submission of Provider Credentials for Interpretive Services  F245-055-000 (English)
Supplemental Agreement Third Party Pharmacy Provider  F249-021-000 (English)
Transfer of Attending Provider Form for Self Insured Workers  F207-114-000 (English)
 F207-114-999 (Spanish)
Vocational Provider Application  F252-088-000 (English)





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