Formulario para trasferencia de proveedor principal para trabajadores autoasegurados


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Title Formulario para trasferencia de proveedor principal para trabajadores autoasegurados
Description

Formulario: Es utilizado por los trabajadores autoasegurados que desean transferir su cuidado médico. Los trabajadores autoasegurados deben completar este formulario y enviarlo a su empleador o a su Representante de Terceros.

Document number F207-114-999
How to get this document
  • Download (25 KB MS Word .doc) 
  • Call the Self-Insurance Section of L&I, 360-902-6898 or fax your request to 360-902-6977. Please have the document number ready so we can process your request quickly. The title is also helpful.
Alt Language(s) English
Valid dates 12/2012
Contact information Self-Insurance
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