Your search for "reimbursement" returned 31 documents.
| Title | Type | Number |
|---|---|---|
| Complete Stay at Work Guide for Employers, The
Booklet: Explains Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Provides information on reimbursements, what is covered and how to apply. Detailed Q&A section included. |
Publication | F243-005-000 |
| Option 2 Vocational Benefits Training Enrollment Application and Verification
Also available in: English/Spanish State fund workers who have selected Option 2 and closed their claim can use this form to apply for access to their Option 2 training funds. To seek reimbursement, use form F245-030-000 Statement for Retraining and Job Modification Services. |
Form | F280-024-000 |
| Overpayment Reimbursement Fund Request Coversheet
This form is a coversheet used by Self-Insurance for overpayment reimbursement fund requests. |
Form | F207-212-000 |
| Statement for Crime Victim Miscellaneous Services
Used by the provider or supplier for reimbursement of the following services - dental, glasses, home health, nursing home serivces, medical equipment, prosthetics-orthotics, transportation, vocational, retraining and other. |
Form | F800-076-000 |
| Statement for Pharmacy Services
Bill form for prescription charges. May be used by a pharmacy to submit drug charges, or by a worker to request reimbursement for prescriptions paid out of pocket. See the General Provider Billing Manual (F248-100-000) for information on completing this form. |
Form | F245-100-000 |
| Stay at Work: A new program to help employers keep injured workers on the job--pays half the wage plus expenses (Programa permanezca en el trabajo - Un nuevo programa para ayudar a los empleadores a mantener a los trabajadores lesionados en el trabajo
Also available in: English Pamphlet/booklet: Provides an overview Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Includes information on eligibility, how to apply, and where to get more information. |
Publication | F243-006-999 |
| Stay at Work: A new program to help employers keep injured workers on the job--pays half the wage plus expenses
Also available in: Spanish Pamphlet/booklet: Provides an overview Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Includes information on eligibility, how to apply, and where to get more information. |
Publication | F243-006-000 |
| Transportation Cost Encumbrance
To record the costs for transportation. For use only with plans approved after 1/1/2008. |
Form | F245-375-000 |
| Travel Reimbursement Request - Spanish Solicitud para el reembolso de gastos de viaje
Also available in: English Injured workers use this form to request reimbursement for travel expenses used to receive treatment, retraining and/or vocational services. |
Form | F245-145-999 |
| Travel Reimbursement Request
Also available in: Spanish Bill form for use by workers to request reimbursement for authorized travel expenses. |
Form | F245-145-000 |
| Cholinesterase Monitoring Reimbursement Request
Employers use this form to request reimbursement for the reasonable costs of training, travel, recordkeeping, and medical expenses for Cholinesterase Monitoring. |
Form | F413-062-000 |
| 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 |
| Helping Providers Understand the Crime Victims Compensation Program
Fact sheet: Answers questions doctors and mental health counselors may have about the Crime Victims Compensation Program and billing for services. Also suggests steps these providers can take to speed up reimbursement. |
Publication | F800-102-000 |
| Instructions in Spanish for completing the form F245-072-000 Statement for Miscellaneous Services
Also available in: English Instructions in Spanish for completing the form F245-072-000 Statement for Miscellaneous Services |
Form | F245-072-999 |
| L&I Toolkit for Providers and Billing
CD: Includes informational materials for new providers. Also contains the rules and policies for reimbursing medical services and lists maximum fees. This CD was previously titled Medical Aid Rules and Fee Schedules. To access the fee schedules, see the "Fee Schedules" Web page listed on the full description page for this publication. |
CD | F245-094-034 |
| Option 2 Vocational Benefits Training Enrollment Application/Aplicación y verificación del registro(English/Spanish)
Also available in: English State fund workers who have selected Option 2 and closed their claim can use this form to apply for access to their Option 2 training funds. To seek reimbursement, use form F245-030-000 Statement for Retraining and Job Modification Services. |
Form | F280-024-909 |
| Social Security Offset Calculations Only Quarterly Statement of Supplemental Benefits Paid for Self-Insured Employers
Used by self-insured employers to request reimbursement from L&I for cost-of-living-adjustments paid to injured workers. |
Form | F207-011-222 |
| Statement for Compound Prescription
Bill form for use by pharmacies and home infusion companies to submit compound drug charges. This form is for drug charges only, and is filled out by the pharmacist. See the Pharmacy Billing Instructions (F248-021-000) for information on completing this form. |
Form | F245-010-000 |
| Statement for Crime Victims Mental Health Services
Used by the Crime Victims Compensation Program providers for reimbursement of Mental Health Services. |
Form | F800-025-000 |
| Statement for Home Nursing Services
Used to bill L&I for reimbursement of home nursing services. |
Form | F248-160-000 |
| Statement for Home Nursing Services - Crime Victims
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 |
| Statement for Pharmacy Services - Crime Victims
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 |
| Statement for Retraining and Job Modification Services
Bill form for providers that bill the department for claim-related retraining and job modification services. See the Retraining and Job Modification Billing Instructions (F248-015-000) for information on completing this form. |
Form | F245-030-000 |
| Stay at Work Expense Reimbursement Application for Employers Tools, Clothing, Training.
Employer of record can request reimbursement for tools, clothing, or training expenses required to enable an injured worker to return to light duty or transitional work. After completing the form, the employer submits it, along with supporting documentation, to the Stay at Work program for review and approval. For wage reimbursements see F243-001-000. |
Form | F243-003-000 |
| Stay at Work Wage Reimbursement Application for Employers
Employer of record can request reimbursement for wages paid to an injured worker during light duty or transitional work. After completing the form, the employer submits it, along with supporting documentation, to the Stay at Work program for review and approval. For expense reimbursements see F243-003-000. |
Form | F243-001-000 |
| 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 |
| Your Independent Medical Exam
Also available in: Spanish 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, Publication | F245-224-000 |
| Your Independent Medical Exam (IME)/Su Examen Médico Independiente (Spanish)
Also available in: English 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, Publication | F245-224-999 |
| 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
Also available in: Spanish 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 |
| Your Independent Medical Exam: For Employees of Self-Insured Businesses - Spanish (Su Examen Médico Independiente: Para empleadores de negocios autoasegurados)
Also available in: English 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 |
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