Out-of-Country Providers — Apply for a Provider Account

If you are a provider who is providing services outside of the United States, you will need to submit the following application for us to pay you for your services rendered:

• Out-of-Country Provider Account Application (F248-361-000), English
• Solicitud de cuenta como proveedor fuera del país (F248-361-999), Spanish

If payment for services are being issued to a hospital, facility or clinic, the W-8BEN-E form is required instead of the W-8BEN. Please click on the following link, below, to download and complete W-8BEN-E:

• IRS W-8BEN-E Form (F248-371-000), English
• Formulario W-8BEN-E del IRS (F248-371-999), Spanish

Please note: Hospitals, facilities or clinics who receive payment for services, do not need to complete the W-8BEN that is included with the Out-of-Country Provider Account Application. The W-8BEN is for individual providers only.

Submit your completed application by fax or US mail to:

Fax: 360-902-4484

Mail:
Washington State Department of Labor & Industries
Provider Accounts and Credentialing
PO Box 44261
Olympia, WA 98504-4261
United States of America

Next steps

Allow 60 - 90 days for review of your application. We will notify you of our decision. If you are accepted, you will receive a letter notifying you of your provider account number. After 90 days, if you have not heard from us, please email us at PACMail@Lni.wa.gov.

Changes to your account

Changes may cause bill payment delays and access issues with L&I's online applications, such as Provider Express Billing and your My L&I account. 

To prevent delays, make sure everyone in your organization knows about the change, including billing staff and staff at individual clinic locations. 

1. For new locations or a new business, submit the Out-of-Country Provider Account Application (F248-361-000), and follow the steps outlined above.
2. For address, name, account closures or other changes on existing accounts, providers must:
   1. Complete, print and sign:
      • Out-of-Country Change Form (F245-469-000, English, or
      • Solicitud de cuenta como (Change form), (F245-469-999), Spanish
   2. Changing your name?
      1. Individual providers who are changing their name, please include one of the following: 
         • Updated Medical License
         • Marriage Certificate
         • Divorce Decree, or
         • Court ordered documents with your new name.
      2. For hospitals, facilities or clinic name changes, please include a copy of your facility license, certification and/or accreditation that includes the new name.

Submit your completed forms by fax or U.S. mail to:

Fax: 360-902-4484

Mail:
Washington State Department of Labor & Industries
Provider Accounts and Credentialing
PO Box 44261
Olympia, WA 98504-4261
United States of America