Obtenga un formulario o publicación

Escriba todo el título del documento o una parte, la descripción o el número:     

Formularios más populares  |  Carteles requeridos del lugar de trabajo  |  Formularios y publicaciones en español


Resultados para: commercial residential structure
Vea:    Ordenar por:       
Título/Descripción:

Búsqueda de palabras clave:  
Tipo:

Attending Provider's Return-to-Work Desk Reference
Book: Discusses best practices in occupational medicine that help return an injured worker to his/her job as soon as medically possible. Identifies resources available from L&I and explains how to bill for return-to-work services. Three hours of Category 1 CME credit are offered for completing an online self-assessment. Go to www.CMECredits.Lni.wa.gov.

Publicación
F200-002-000
 
Provider's Initial Report (PIR)

Used by medical providers when reporting initial treatment for an industrial injury or occupational disease for a self-insured claim.

Medical providers treating self-insured workers, self-insured businesses, or their third party claims administrators can access this form one of two ways:

  1. Download the Microsoft (MS) Word form and the PDF file with instructions:

           The first file is the PDF instructions.

           The second file is an Office 2003 MSWord document ending in .doc.

           The third file is an Office 2007/2010 version, ending in .docx.

2.  Order paper copies of this form by clicking the “order it” button.



Formulario
F207-028-000
 
Transfer of Attending Provider Form for Self Insured Workers

This form is used by self-insured injured workers who want to transfer their medical care.  Self-insured workers should complete the form and send it to their employer or their Third Party Representative.



Formulario
F207-114-000

Otro(s) idioma(s):
Español
 
Self-Insurance Medical Provider Billing Dispute form

A form for Providers to submit disputes to the department regarding payment of medical provider bills



Formulario
F207-207-000
 
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
 
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
 
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
 
Provider's Request for Adjustment

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



Formulario
F245-183-000
 
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
 
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
 
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
 
Non-Network Provider Application

Includes the F248-036-000 Statewide Payee Registration and W-9 form. For providers to complete that do not want to become a Labor and Industries network provider, or for a specialty that L&I is not accepting network applications for at this time. If you are applying to be a Labor and Industries network provider, please complete application process at www.ProviderNetwork.Lni.wa.gov



Formulario
F248-011-000
 
Hotline Tips for Medical Services Providers
Fact sheet: Provides tips to help medical service providers quickly obtain answers to claims and billing questions. Introduces L&I's Provider Hotline, Interactive Voice Response Message System and online Claim & Account Center.

Publicación
F248-040-000
 
General Provider Billing Manual

General billing information for those providers that bill the department.



Manual
F248-100-000
 
Payroll Service Provider - Quarterly Reporting Bulk Filing Enrollment Form

Used by payroll services to enroll and register with L&I for downloading/uploading account information from the Express Filing site using an electronic list (text file) of accounts.



Formulario
F248-343-000
 
Out of Country Provider Application

This application is for providers outside the United States. Providers who treat injured workers must have a provider number to bill the department.



Formulario
F248-361-000

Otro(s) idioma(s):
Español
 
Supplemental Agreement Third Party Pharmacy Provider

This agreement is to define access, performance and legal requirements for third party pharmacy billers who submit bills to and receive payment from L&I on behalf of pharmacy providers. This agreement authorizes L&I to accept and remit monies due the Pharmacy using a third party pharmacy biller.



Formulario
F249-021-000
 
Individual Vocational Provider Account Change Form

To change an individual's (service provider's) name, add or delete referral categories, update certifications, leaving a firm, intern supervisor changes, and/or adding or deleting a branch for referrals.



Formulario
F252-021-000
 
Firm Vocational Provider Account Change

To change a firm's (payee provider's) branch address within the same service location, contact info, tax info, adding or deleting designee for your firm.



Formulario
F252-022-000
 
Vocational Provider Application

Complete this application and the StateWide Payee W-9 if you are applying for a firm Provider Number with L&I.



Formulario
F252-088-000
 
On-The-Job Training (OJT) Agreement for Vocational Providers

On-The-Job Training (OJT) Agreement for Vocational Providers



Formulario
F280-039-000
 
Non-accredited or Unlicensed Training Provider Application Supplemental Requirements

Used by non-accredited or unlicensed training providers in order to be reviewed for approval to become a training provider for Washington injured workers. Must be submitted with the Provider Account Application (F248-011-000).



Formulario
F280-045-000
 
Cholinesterase Monitoring Health Care Provider Recommendations

Filled out by the provider. This form gives the recommendations by the provider of what needs to be done based on the test results on the employee.



Formulario
F413-070-000

Otro(s) idioma(s):
Español
Español
 
Elevator Continuing Education Provider / Instructor Application

Application to become an instructor or provider for elevator related courses.



Formulario
F621-078-000
 
Master Level Counselor Provider Account Application for Crime Victims

Master Level Counselor Provider Account Application for Crime Victims



Formulario
F800-053-000
 
Crime Victims Provider's Request for Adjustment

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.



Formulario
F800-064-000
 
Provider Change Form for Crime Victims Compensation

Providers use to inform L&I that they have changes to their account. Such as changes to their Tax ID address/name, business address, billing address, name, or termination of account. This also includes a W-9 form.



Formulario
F800-089-000
 
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.

Publicación
F800-102-000
 
Need a Doctor?

Information card: Provides contact information for injured workers needing assistance in finding a health-care provider who will treat their occupational injury or disease. This PDF will print out an 8.5" X 11" sheet that has 12 copies of the card. Note: Disclaimer information on Page 2 may not line up accurately in two-sided printing.



Publicación
F160-006-000

Otro(s) idioma(s):
Español
 
Application to Reopen Claim Due to Worsening Condition

This application is by injured workers and providers to apply to reopen an industrial injury or occupational disease claim due to worsening condition for claims that have been claims 60 days or longer.



Formulario
F242-079-000

Otro(s) idioma(s):
Inglés/Español
Español
 
Report of Accident (ROA) Workplace Injury, Accident or Occupational Disease

This form is not available to download. If you are an injured worker, ask your medical provider for a copy of this form or you can complete your portion of the Report of Accident (ROA) online at www.FileFast.Lni.wa.gov. Please note only medical providers may order this form from the Warehouse.

Our supply of paper ROAs is limited, but medical provider offices can file their Report of Accident (ROA) within 30 minutes online through FileFast at www.FileFast.Lni.wa.gov. Filing online gives you immediate claim confirmation and speeds claim processing by 5 days.  Provider offices also can get reimbursed $10 (billing code 1040M) for each ROA filed online.

We anticipate receiving additional ROAs in our Warehouse by February 9, 2015.



Formulario
F242-130-000
 
Notice of Occupational Disease or Infection

Used by medical providers to notify L&I that an occupational disease or infection has been diagnosed and that the worker has been advised that their condition may be work-related. This form can be used if the worker does not complete a Report of Accident or Occupational Disease (ROA) but should not be completed in place of an ROA.



Formulario
F242-243-000
 
Activity Prescription Form (APF)

This form is used by health-care providers to communicate an injured worker's status, physical capacities, inability to work (time-loss) and treatment plans.



Formulario
F242-385-000
 
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
 
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
 
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
 
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
 
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
 
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
 
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
 
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
 
Occupational or Physical Therapy Treatment Authorization Fax Request

Used by a therapy provider/clinic to request authorization for outpatient occupational or physical therapy services for L&I claims.



Formulario
F248-055-000
 
Power of Attorney for Electronic Remittance Advice

Providers complete this form to authorize a clearinghouse or third party to receive the EDI 835 Electronic Remittance Advice file from L&I's Provider Express Billing (PEB).



Formulario
F248-355-000
 
Medical Payment Guidance

Flyer: Describes how a payment for health-care services is mailed separately from the explanation for the payment (the remittance advice). An illustration explains how to link a payment with its explanation. Also includes information about how providers can always find their remittance advices online through L&I's Provider Express Billing.



Publicación
F248-366-000
 
Medical Examiners' Handbook

Book: A publication for independent medical examiners, attending doctors and consultants, this document contains guidelines, sample reports and billing procedures for preparing and conducting impairment ratings and independent medical exams in Washington's workers' compensation system. Beginning July 1, 2012, free Category I CME credits are available for completing the self-assessment associated with this handbook. Go to www.Imes.Lni.wa.gov and click on Medical Examiners Handbook for information on the exam. L&I and the authors have no financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this document. Find a medical examiner.



Publicación
F252-001-000
 
Attending Doctor's Handbook

Note: The October 2012 update edition contains limited new information, including a summary of recent workers' compensation reforms. The inside pages remain the same as the 03-2005 edition. This handbook contains useful information to help providers who treat patients in the workers' compensation system. Physicians can obtain 3 hours of CE credit by completing an online self-assessment based on this handbook. L&I and the authors have no financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this document.



Publicación
F252-004-000
 
Assessment Closing Report

Used by only private sector vocational rehabilitation providers to document vocational assessment to determine if a worker is employable based upon transferable skills.



Formulario
F252-029-000
 
Targeting Fraud and Abuse in Washington State's Workers' Compensation Program: 2008 Report to the Legislature
Booklet/Pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided.

Publicación
F262-032-000
 
Targeting Fraud and Abuse in Washington State's Worker's Compensation Program: 2005 Report to the Legislature
Booklet/pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided.

Publicación
F262-251-000
 
Application to Establish an Factory Assembled Structure Deposit Account with the Dept. of Labor and Industries

Use to establish a factory assembled structure (FAS) deposit account. FAS deposit accounts are for businesses or other entities that are not currently licensed or registered with L&I as electrical or construction contractors but are legally required to purchase work permits from L&I. (3 pgs)



Formulario
F120-116-000
 
Workers' Comp Fraud Hurts YOU
Pamphlet: Explains the impacts of workers' comp fraud and L&I's efforts to prevent and find fraud by workers, employers, contractors, and medical providers.

Publicación
F262-279-000
 
Plan Approval Request - Factory Built Structures and Commercial Coaches

A manufacturer of factory-built structures and/or commercial coaches uses this form to submit plans to L&I for review.



Formulario
F623-006-000
 
Request for Preferred Workers Status

Used by vocational providers to apply for preferred worker status on behalf of an industrially injured worker.



Formulario
F280-023-000
 
Notification to Local Enforcement Agency

L&I sends this form to notify the local agencies when a factory-built structure is being shipped within a county or city limits.



Formulario
F623-013-000
 
Vocational Questionnaire/Work History

Vocational Questionnaire/Work History for use by Vocational Providers serving injured workers.



Formulario
F280-038-000

Otro(s) idioma(s):
Español
 
Application for Insignia for Factory Assembled Structures

Manufacturers uses this form to apply for an official insignia for a factory-built structure that has a plan approval number.



Formulario
F623-014-000
 
Account Deposit for Factory Assembled Structures Account Holders

You must have a contractor license number or have completed an application for a miscellaneous account to use this form.



Formulario
F622-081-000
 





End of main content, page footer follows.

Access Washington en Español

© Depto. de Labor e Industrias del Estado de Washington. El uso de éste sitio del Internet está sujeto a las leyes del Estado de Washington.