Forms and Publications

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Results for: Claims and Insurance - For Medical Providers
Title:

Type:

¿Necesita un doctor?


Publication
F160-006-999

World Language(s):
Inglés
 
3 Things to Know about L&I's Medical Provider Network


Publication
F242-406-000

World Language(s):
Español
 
Activity Prescription Form (APF)


Form
F242-385-000
 
Attending Doctor's Handbook


Publication
F252-004-000
 
Authorization to Release Information


Form
F262-005-000

World Language(s):
Español
 
Billing Guidelines for Sexual Assault Examinations: Crime Victims Compensation Program


Manual
F800-100-000
 
Cómo hacer la mejor elección de tratamiento para el dolor crónico en la parte inferior de su espalda


Publication
F252-081-999

World Language(s):
Inglés
 
Chronic Opioid Request Form


Form
F252-091-000
 
Convenio para el tratamiento con opioides


Form
F252-095-999

World Language(s):
Inglés
 
Crime Victim Compensation Program Sexual Assault Exam Report


Form
F800-098-000
 
Crime Victims Compensation Program Progress Note: Form III


Form
F800-082-000
 
Crime Victims Compensation Program Termination Report: Form VI


Form
F800-085-000
 
Crime Victims Compensation Program Treatment Report: Form IV


Form
F800-083-000
 
Crime Victims Compensation Program Treatment Report: Form V


Form
F800-084-000
 
Crime Victims Statement for Home Nursing Services


Form
F800-070-000
 
Department of Labor and Industries Home Modification Acknowledgement of Responsibilities


Form
F247-003-000

World Language(s):
Español
 
Doctor's Worksheet for Rating Cervical and Cervico-Dorsal Impairment


Form
F252-056-000
 
Doctor's Worksheet for Rating Dorso-Lumbar & Lumbo-Sacral Impairment


Form
F252-006-000
 
Electronic Billing Authorization


Form
F248-031-000
 
Functional Recovery Interventions Tracking Sheet


Publication
F245-420-000
 
Hearing Aid Replacement Form


Form
F242-414-000
 
Hearing Impairment Calculation Worksheet


Form
F252-007-000
 
Home Modification for Workers with Catastrophic Injuries - Questions and Answers for Contractors


Publication
F252-061-000
 
Independent Medical Exam Doctor's Estimate of Physical Capacities


Form
F242-387-000
 
Independent Medical Examination (IME) Provider Exam Sites


Form
F245-047-000
 
Individual Vocational Provider Account Change Form


Form
F252-021-000
 
Interpreter Services for Injured Workers and Crime Victims


Publication
F245-412-000

World Language(s):
Español
 
L&I Chiropractic Consultant Application


Form
F245-393-000
 
Labor and Industries Prosthetic Device Request Form


Form
F245-340-000
 
Long Term Care Assessment Tool


Form
F245-377-000
 
Medical Device Review Request


Form
F252-013-000
 
Medical Examiners' Handbook


Publication
F252-001-000
 
Mental Health Services Fee Schedule


Publication
F245-422-000
 
Modificaciones de la vivienda para trabajadores con lesiones catastróficas – Preguntas y respuestas para contratistas


Publication
F252-061-999

World Language(s):
Inglés
 
Modificaciones de la vivienda para trabajadores con lesiones catastróficas


Publication
F252-060-999

World Language(s):
Inglés
 
Need a Doctor?


Publication
F160-006-000

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


Form
F248-011-000
 
Notice of Occupational Disease or Infection


Form
F242-243-000
 
Opioid Treatment Agreement


Form
F252-095-000

World Language(s):
Español
 
Performance Based Physical Capacities Evaluation


Form
F245-023-000
 
Power of Attorney for Electronic Remittance Advice


Form
F248-355-000
 
Pre-Job Accommodation Assistance Application


Form
F245-350-000

World Language(s):
Español
 
Preauthorization Request for Services for State Fund Workers' Compensation Patients


Form
F242-397-000
 
Provider Account Application - Independent Medical Examiner (IME)


Form
F245-046-000
 
Provider Change Form for Crime Victims Compensation


Form
F800-089-000
 
Provider Payment Account Change Form


Form
F245-365-000
 
Provider's Initial Report (PIR)


Form
F207-028-000
 
Quick Reference Card for Providers


Publication
F245-414-000
 
REFUND NOTIFICATION Refunding Money to L&I to correct your account?


Form
F245-043-000
 
Report of Accident (ROA) Workplace Injury, Accident or Occupational Disease


Form
F242-130-000

World Language(s):
Español
 
Sample Format for Vocational Testing Report


Form
F252-051-000
 
Sample Self-Employment Agreement


Form
F252-032-000
 
Statement for Compound Prescription


Form
F245-010-000
 
Statement for Home Nursing Services


Form
F248-160-000
 
Statement for Retraining and Job Modification Services


Form
F245-030-000

World Language(s):
Español
 
Statewide Payee Registration and W-9 Form


Form
F248-036-000
 
Su examen médico independiente: para empleadores de negocios autoasegurados


Publication
F207-202-999

World Language(s):
Inglés
 
Subacute Opioid Request Form


Form
F252-097-000
 
Tres cosas que debe conocer sobre la Red de proveedores médicos de L&I


Publication
F242-406-999

World Language(s):
Inglés
 
UB04 HCFA 1450


Form
F245-367-000
 
Vocational Training Plan Ownership Agreement for Tools and Equipment


Form
F245-351-000

World Language(s):
Español
 
Attending Provider's Return-to-Work Desk Reference


Publication
F200-002-000
 
Frequently Asked Questions about Job Modifications


Publication
F245-057-000
 
Helping Providers Understand the Crime Victims Compensation Program


Publication
F800-102-000
 
Home Modification for Workers with Catastrophic Injuries


Publication
F252-060-000
 
Hotline Tips for Medical Services Providers


Publication
F248-040-000
 
Making the Best Treatment Choice for Your Chronic Low-back Pain


Publication
F252-081-000
 
Medical Payment Guidance


Publication
F248-366-000
 
Stay at Work Exam Room Card


Publication
F243-009-000
 
Your Independent Medical Exam (IME): Crime Victims Compensation Program


Publication
F800-115-000
 
Your Independent Medical Exam: For Employees of Self-Insured Businesses


Publication
F207-202-000

World Language(s):
Español
 





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