Providers use this to report total overpayment, partial overpayment and/or underpayment by L&I. These forms will be accepted by L&I. They may not be accepted by all Medical Bill Processors due to lack of a barcode.

Used by employers to present L&I with a list of decisions they are protesting by adjustment period. The form requests all necessary elements needed for L&I to process a request for reconsideration.

Used by providers to request an adjustment to their bill if their entire bill was paid in error, or if a portion of the bill was overpaid or underpaid. Attach required reports and/or documentation to support the request.

Used by self-insured employers to request reimbursement from L&I for cost-of-living-adjustments paid to injured workers.