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.

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

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.