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Solicitud para beneficios de pensión presentado por el cónyuge o los hijos

Formulario:  Usado por el cónyuge o dependiente elegido por el trabajador fallecido para recibir un beneficio de sobreviviente.  En el momento en que se determinó que el trabajador estaba permanentemenre y totalmente discapacitado el/ella tomó la decisión de dejar el beneficio de sobreviente al cónyuge o dependiente si el trabajador fallecía.



Formulario
F242-391-999

Otro(s) idioma(s):
Inglés
 
Pension Benefits Questionnaire

Used by an injured worker who receives an order that states he or she is totally permanently disabled. This questionnaire must be completed in full and all necessary documents attached before his or her pension benefit options can be calculated.



Formulario
F242-393-000

Otro(s) idioma(s):
Español
 
Cuestionario para beneficios de pensión

Usado por un trabajador lesionado que recibe una orden estableciendo que él o ella está total y permanentemente discapacitado.  Este cuestionario debe completarse en su totalidad y debe adjuntarse todos los documentos necesarios antes de que pueda calcularse sus opciones de beneficios de pensión.



Formulario
F242-393-999

Otro(s) idioma(s):
Inglés
 
Affidavit for Time Loss Compensation Benefits

Completed by injured workers contending eligibility for payment of back time loss benefits for a period that exceeds six months or $25,000. Injured workers requesting benefits for current time missed from work due to a work-related injury should use the F242-052-000 Worker Verification Form.



Formulario
F242-395-000

Otro(s) idioma(s):
Español
 
Declaración firmada para compensación de tiempo perdido

Para ser completada por los trabajadores lesionados que reclaman que tenian derecho a recibir el pago de beneficios de tiempo perdido no pagados anteriormente por un periodo que excede seis meses o $25,000.  Los trabajadores lesionados que soliciten beneficios por el tiempo perdido de trabajo actual debido a una lesión relacionada con el trabajo deben usar el Formulario de verificación de empleo, F242-052-999.



Formulario
F242-395-999

Otro(s) idioma(s):
Inglés
 
Preauthorization Request for Services for State Fund Workers' Compensation Patients

This form can only be used for services that can be authorized by the claim manager and it should not be used for Utilization Review (Qualis), Provider Hotline or requests to the Occupational Nurse Consultant.  If you are unsure of what services need to be authorized see L&I fee lookup utility at www.Lni.wa.gov/apps/FeeSchedules/

For complete information on all authorization processes please see:  www.Lni.wa.gov/ClaimsIns/Providers/AuthRef/GetAuth.asp



Formulario
F242-397-000
 
FileFast postcard handout for workers
Handout (4.25 x 6): Explains to workers why and how to file an accident report online or by phone following an injury; also reminds them to stay in contact with employer and L&I.

Publicación
F242-398-000
 
FileFast poster for workers
Poster (8.5 x 11): Explains to workers why and how to file an accident report online or by phone following an injury and reminds them to stay in contact with employer and L&I.

Cartel
F242-399-000
 
FileFast wallet card for workers
Wallet card (3.5 x 2): Reminds workers of FileFast web address and number for call center.

Publicación
F242-400-000
 
Se ha lesionado en el trabajo?

Tarjeta para billetera:  Explica cómo presentar un reclamo de compensación para los trabajadores por teléfono.



Publicación
F242-404-999
 
3 Things to Know about L&I's Medical Provider Network

Handout: Explains to workers the basic information about L&I’s Medical Provider Network. The handout can be used with workers covered both by L&I and by self-insured employers. Applies to workers in Washington state. Includes website and phone number contact information.



Publicación
F242-406-000

Otro(s) idioma(s):
Español
 
Tres cosas que debe conocer sobre la Red de proveedores médicos de L&I

Volante: Le explica a los trabajadores la información básica sobre la Red de proveedores médicos de L&I. Los trabajadores cubiertos por L&I y por las empresas autoaseguradas pueden utilizar el volante.  Se aplica a los trabajadores en el estado de Washington.  Incluye información para comunicarse por la Internet y el número de teléfono.  



Publicación
F242-406-999

Otro(s) idioma(s):
Inglés
 
Chemical Exposure Questionnaire Packet

Packet that contains:

F242-409-000 Chemical Exposure Questionnaire

F242-410-000 Worker Release for Union Dispatch Records

F262-005-000 Authorization to Release Information

Request for Social Security Earnings Information with the L&I address.



Formulario
F242-409-000

Otro(s) idioma(s):
Español
 
Cuestionario de exposición a sustancias químicas

Formulario: Contiene el  Cuestionario de exposición a sustancias químicas F242-409-999, la Autorización para proveer información  F262-005-999 y la versión en inglés solamente de un formulario del Seguro Social que contiene la información apropiada de L&I.



Formulario
F242-409-999

Otro(s) idioma(s):
Inglés
 
Autorization del trabajador para obtener registros de trabajos despachados por el sindicato

Autorización del trabajador para obtener registros de trabajos despachados por el sindicato.



Formulario
F242-410-999

Otro(s) idioma(s):
Inglés
 
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.



Formulario
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.



Formulario
F243-003-000
 
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.



Publicación
F243-005-000
 
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.



Publicación
F243-006-000

Otro(s) idioma(s):
Español
 
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

Folleto: Proporciona un resumen del programa Permanezca en el Trabajo, un programa con un incentivo económico que anima a los empleadores del estado de Washington a encontrar trabajos livianos o de transición para trabajadores que se están recuperando de lesiones ocurridas en el trabajo. Incluye información sobre los requisitos que deben reunir, cómo hacer una solicitud y donde pueden obtener más información.



Publicación
F243-006-999

Otro(s) idioma(s):
Inglés
 
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.



Formulario
F245-010-000
 
Performance Based Physical Capacities Evaluation

Used by occupational and physical therapy providers as an optional reporting format for a Performance-based Physical Capacities Evaluation.



Formulario
F245-023-000
 
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.



Formulario
F245-030-000

Otro(s) idioma(s):
Español
 
Declaración de servicios de capacitación y modificación de trabajo

Formulario:  Para ser completado por los proveedores que facturan al Departamento por capacitación y servicios de modificación de trabajo.



Formulario
F245-030-999

Otro(s) idioma(s):
Inglés
 
Transfer of Care Card

Used by injured worker to notify claim manager and request authorization to transfer care to a different doctor. Do it online! Use the online Transfer of Care



Formulario
F245-037-000

Otro(s) idioma(s):
Español
 
Tarjeta para transferencia de caso

Usada por los trabajadores lesionados para notificar al gerente de reclamo y solicitar autorización para transferir el cuidado a un doctor diferente.



Formulario
F245-037-999

Otro(s) idioma(s):
Inglés
 
REFUND NOTIFICATION Refunding Money to L&I to correct your account?

Used to Refund Money to L&I to correct your account REFUND NOTIFICATION



Formulario
F245-043-000
 
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.



Formulario
F245-046-000
 
Independent Medical Examination (IME) Provider Exam Sites

List the locations where the doctor does independent medical exams on a regular basis.



Formulario
F245-047-000
 
Hearing Services Worker Information

This is a list of the rights and conditions when an injured worker applies for hearing aids.



Formulario
F245-049-000
 
Termination of Agreement (Rescission)
To be filled out by the injured worker who wants to return hearing aids.

Formulario
F245-050-000
 
Approved Independent Medical Examiner (IME) Update
To update or correct the IME's contact, availability, qualificaitons and/or exam sites.

Formulario
F245-051-000
 
Independent Medical Exam Comments
Used by the injured worker to provide comments to L&I about their recent medical exam by an IME.

Formulario
F245-053-000

Otro(s) idioma(s):
Español
 
Comentarios Sobre el Exámen Médico Independente

Usado por el trabajador lesionado para proporcionarle comentarios a L&I sobre su examen médico reciente de un Examen Médico Independiente (IME, por su sigla en inglés).



Formulario
F245-053-999

Otro(s) idioma(s):
Inglés
 
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.



Formulario
F245-055-000
 
Interpretive Services Appointment Record (ISAR)

This form is used by interpreters to verify to L&I (state fund and Crime Victims claims) and self-insured employers for interpretive service at medical or vocational visits.

When ordering, there is a limit of 4 pads, or 100 copies total.



Formulario
F245-056-000
 
Frequently Asked Questions about Job Modifications
Fact sheet: Answers questions employers, workers and doctors may have about job modifications, including when to request a job-modification consultant and who pays for the costs involved.

Publicación
F245-057-000
 
Independent Medical Exam Template
Template used by a doctor during an independent medical exam.

Formulario
F245-058-000
 
Physical Therapy / Occupational Therapy Progress Report to Claim Managers

The physical / occupational therapist uses this report to identify the clinical goals and return to work objectives of the injured worker.



Formulario
F245-059-000
 
Statement for Miscellaneous Services

This bill form is used by providers and injured workers to bill the department for services such as dental care; glasses; medical equipment; nursing home services; interpreter services; services workers pay for out of pocket; and other services. Information on how to bill the department can be found in the General Provider Billing Manual [F248-100-000].

 



Formulario
F245-072-000

Otro(s) idioma(s):
Español
 
Declaración para servicios misceláneos

Formulario:  Es utilizado por proveedores y trabajadores lesionados para cobrarle al Departamento por servicios tales como, cuidado dental; lentes; cuidado de enfermería en el hogar; equipo médico, servicios de intérprete; servicios que los trabajadores pagan por su cuenta y otros servicios.



Formulario
F245-072-999

Otro(s) idioma(s):
Inglés
 
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.



Formulario
F245-100-000
 
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.

Formulario
F245-127-000
 
Travel Reimbursement Request

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



Formulario
F245-145-000

Otro(s) idioma(s):
Español
 
Solicitud para el reembolso de gastos de viaje

Los trabajadores lesionados usan este formulario para solicitar reembolso de los gastos de viaje usados para recibir tratamiento, capacitación y/o servicios vocacionales.



Formulario
F245-145-999

Otro(s) idioma(s):
Inglés
 
Provider's Request for Adjustment

Providers use this to report total overpayment, partial overpayment and/or underpayment by L&I.



Formulario
F245-183-000
 
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.



Formulario
F245-224-000

Otro(s) idioma(s):
Español
 
Su examen médico independiente

Folleto: Respuestas a las preguntas más comunes sobre los exámenes médicos independientes y cuándo y por qué podría requerirse que un trabajador lesionado asistiera a uno.  Incluye el formulario examen médico independiente (IME, por su sigla en inglés) - Solicitud para el reembolso de gastos de viaje y salario. Este formulario es solamente para el uso de negocios autoasegurados y sus trabajadores.



Formulario
F245-224-999

Otro(s) idioma(s):
Inglés
 
Labor and Industries Prosthetic Device Request Form

Labor and Industries Prosthetic Device Request



Formulario
F245-340-000
 
Job Modification Assistance Application

For use by an vocational counselor, employer, etc. to request modification for the injured workers job. This may involve tools and equipment that is purchased through L&I.



Formulario
F245-346-000

Otro(s) idioma(s):
Español
 
Modificacion en el trabajo solicitud de asistencia

Para ser utilizado por un consejero vocacional, empleador, etc. para solicitar modificación de empleo para el trabajador lesionado.  Esto puede incluir herramientas y equipo comprado por L&I.  



Formulario
F245-346-999

Otro(s) idioma(s):
Inglés
 
Pre-Job Accommodation Assistance Application

For use by a therapist or vocational provider to request job modification for an injured worker before the injured workers is employed, possibly in a retraining program. This may involve tools and equipment that is purchased through L&I.



Formulario
F245-350-000

Otro(s) idioma(s):
Español
 
Adaptación previa al trabajo solicitudad de ayuda

Formulario:  Este formulario puede utilizarlo un terapeuta o proveedor vocacional para solicitar una modificación de empleo para un trabajador lesionado antes de que el trabajador lesionado sea empleado, posiblemente en un programa de capacitación.  Esto puede incluir herramientas y equipo comprado por L&I.





Formulario
F245-350-999

Otro(s) idioma(s):
Inglés
 
Vocational Training Plan Ownership Agreement for Tools and Equipment

Injured worker agrees to the ownership terms of the tools and/or equipment purchased as part of their training plan by L&I.



Formulario
F245-351-000

Otro(s) idioma(s):
Español
 
Acuerdo de propiedad de herramientas y equipo para el plan de formacion profesional

Formulario: El trabajador lesionado está de acuerdo con los términos de propiedad de las herramientas y/o el equipo comprado como parte de su plan de capacitación de L&I.



Formulario
F245-351-999

Otro(s) idioma(s):
Inglés
 
Provider Credentialing Change Form

Providers use this form to notify L&I of a change of their business address, billing address and account termination. Also has info on how to notify L&I on a tax ID (EIN) number change, tax ID address change and/or name change.



Formulario
F245-365-000
 
UB04 HCFA 1450

Used by hospitals to bill L&I for inpatient/outpatient services. This version includes NPI number.



Formulario
F245-367-000
 
Housing and Board Cost Encumbrance
To record the costs for housing and board. For use only with plans approved after 1/1/2008.

Formulario
F245-372-000
 
Training Plan Cost Encumbrance

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



Formulario
F245-374-000
 
Transportation Cost Encumbrance

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



Formulario
F245-375-000
 
Plan Time Encumbrance
To record the work plan time. For use only with plans approved after 1/1/2008.

Formulario
F245-376-000
 
Long Term Care Assessment Tool

You must mail or fax form. No emailed forms are accepted. This assessment tool is provided by L&I assessment to determine the medically appropriate level of care that will meet the Injured Worker’s needs, abilities and safety in a residential facility. This assessment is not intended as a substitute for DSHS annual assessment & treatment plan, which is the sole financial responsibility of the facility.



Formulario
F245-377-000
 
Notice of Independent Medical Exam No-Show or Late Cancellation
Notice of Independent Medical Exam No-Show or Late Cancellation

Formulario
F245-382-000
 
Independent Medical Examination Fax Cover Sheet
Independent Medical Examination Fax Cover Sheet

Formulario
F245-383-000
 
Hearing Aid Repair Authorization Fax Request

Hearing Aid Repair Authorization Requests. If you need to purchase or replace a hearing aid, fax all of the information required by Medical Aid Rules and Fee Schedule (MARFS) including the Hearing Services Worker Information (F245-049-000) to 360-902-6252.



Formulario
F245-384-000
 
F245-392-000 Resource Utilization Group (RUG) Residential Care Services for L&I Injured Workers (In place of MDS 3.0 beginning October 1, 2010.)
Filled out by the provider when they treat an injured worker. See web links below for: Latest payment amounts, Updates and corrections, and Review payment policy. For use in place of Minimum Data Set (MDS) 3.0 beginning October 1, 2010.

Formulario
F245-392-000
 
L&I Chiropractic Consultant Application
This application is for doctors applying for second opinion examiner (consultant) status. Current consultants do not need to reapply.

Formulario
F245-393-000
 
HCFA Proprietary Format Companion Guide
This guide details the HCFA proprietary format structure and provides information regarding electronic billing to the department via Provider Express Billing (PEB).

Formulario
F245-394-000
 
Provider Network Agreement
The provider network agreement for participation in the health care provider network for injured workers covered by Washington State Fund and self-insured employers.

Formulario
F245-397-000
 
ASC X12N 005010 EDI Transactions Companion Guide
Description: This guide details the HIPAA ASC X12N 005010 format structure for EDI and provides information regarding electronic billing To the department via Provider Express Billing (PEB)

Manual
F245-398-000
 
Pharmacy Companion Guide
This guide details the HIPAA ASC X12N 004010 format structure for 835 Pharmacy Remittance Advice and provides information regarding electronic billing to the department via Provider Express billing (PEB)

Manual
F245-400-000
 
Washington Practitioner Application

Washington Practitioner Application is used by providers applying for the L&I Provider Network.



Formulario
F245-411-000
 
Interpreter Services for Injured Workers and Crime

Flier: Describes interpreter services available to injured workers and crime victims. Covers how to get an interpreter; who can interpret and get paid for it; and basics of interpreter's professional conduct.



Publicación
F245-412-000

Otro(s) idioma(s):
Español
 
Servicios de intérprete para trabajadores lesionados y víctimas de crimen

Volante: Describe los servicios de intérprete disponible a los trabajadores lesionados y a las víctimas de crimen.  Incluye información de cómo obtener un intérprete; quién puede interpretar y recibir pago; y el concepto básico de conducta profesional del intérprete.



Publicación
F245-412-999

Otro(s) idioma(s):
Inglés
 
Quick Reference Card for Providers

Flyer or small poster for administrative staff for health-care and vocational providers: lists the most frequently used procedure codes and fees. The back highlights the most popular or frequently used web pages for providers and their staff. Provides tips for speeding up authorizations and for billing self-insured employers.



Publicación
F245-414-000
 
Department of Labor and Industries Home Modification Acknowledgement of Responsibilities

Used by both workers and bidding contractors to read, sign and submit to L&I to verify that they have read, understand and accept their respective responsibilities in the home modification process.



Formulario
F247-003-000

Otro(s) idioma(s):
Español
 
Modificacion en la vivienda Reconocimiento de responsabilidades

Utilizada tanto como por los trabajadores y contratistas de licitación para leer, firmar y someter a L&I para verificar que han leído, entendido y aceptado sus responsabilidades respectivas en el proceso de modificación de viviendas



Formulario
F247-003-999

Otro(s) idioma(s):
Inglés
 
Safety Standards for Ethylene Oxide WAC 296-855

Ethylene Oxide is a flammable colorless gas that is commonly used to sterilize medical equipment and as a fumigant for certain agricultural products. It is also used as an intermediary in the production of various chemicals such as ethylene glycol, automotive antifreeze, and polyethylene. Exposure is the contact an employee has with ethylene oxide, whether or not protection is provided by respirators or other personal protective equipment (PPE). Exposure can occur through various routes of entry such as inhalation, ingestion, skin contact, or skin absorption.

 



Manual
F414-132-000
 





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