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Non-accredited or Unlicensed Training Provider Application Supplemental Requirements

Used by non-accredited or unlicensed training providers in order to be reviewed for approval to become a training provider for Washington injured workers. Must be submitted with the Provider Account Application (F248-011-000).



Form
F280-045-000


 
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


 
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
 
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


 
Submission of Provider Credentials for Interpretive Services

Used to apply as a interpretive service provider and to show what language(s) you hold credentials for. F248-011-000 Provider Application and Notice is added to this form.



Form
F245-055-000


 
Washington Practitioner Application

Washington Practitioner Application



Form
F245-411-000


 





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