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Overpayment Reimbursement Fund Request Coversheet

This form is a coversheet used by Self-Insurance for overpayment reimbursement fund requests.



Form
F207-212-000
 
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
 
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
 
Travel Reimbursement Request

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



Form
F245-145-000

Alt Language(s):
Español
 
Travel Reimbursement Request - (Spanish) Solicitud para el Reembolso de Gastos de Viaje

Injured workers use this form to request reimbursement for travel expenses used to receive treatment, retraining and/or vocational services.



Form
F245-145-999

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

Used to bill L&I for reimbursement of home nursing services.



Form
F248-160-000
 
Option 2 Vocational Benefits Training Enrollment Application and Verification

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

Alt Language(s):
English/Español
 
Option 2 Vocational Benefits Training Enrollment Application/Aplicación y Verificación del Registro (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
F280-024-909

Alt Language(s):
Inglés
 
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
 
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
 
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
 
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
 
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
 
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.



Form
F245-010-000
 
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 General Provider Billing Manual (248-100-000) for information on completing this form.



Form
F245-030-000
 
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
 
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
 
Transportation Cost Encumbrance

To record the costs for transportation. For use only with plans approved after 1/1/2008.



Form
F245-375-000
 
Stay at Work: A new program to help employers keep injured workers on the job--pays half the wage plus expenses

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

Alt Language(s):
Español
 
Stay at Work: A new program to help employers keep injured workers on the job--pays half the wage plus expenses (Permanezca en el Trabajo: Una Solución Factible -- Un programa para ayudar a los empleadores a mantener a los trabajadores lesionados en el trabajo -- paga la mitad del salario base además de otros gastos).

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

Alt Language(s):
Inglés
 





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