Use the Modification Guides to:

• Update addresses
• Add or change electronic funds transfer (EFT)
• Inactivate accounts (individual/group/FAOI)
• Add servicing providers
• Change legal and doing business as (DBA) name

Select the modification guide for your account type:

Individual Modification Guide

• Individual billing: A provider who is a sole proprietor and submits their own bills.
• Individual servicing: A provider who works for an entity who bills on their behalf.

Group/FAOI Modification Guide

• Group: An organization of individual providers who offer services.
• FAOI: A facility, agency, organization, or institution that doesn’t have servicing providers.

Adding L&I to an existing provider account

• Use this guide to add L&I to an existing ProviderOne Domain.

Questions? Contact LNIProviderOne@Lni.wa.gov. We’ll respond to your email within three business days.

1. Complete, print and sign the Provider Account Change Form(F245-365-000).

a. Changing your name? 

i. Individual providers changing their name, please include one of the following:

• • • • • • • Updated medical license.
            • Marriage certificate.
            • Divorce decree, or
            • Court ordered documents with your new name.

ii. Facility or hospitals changing legal name, please include a copy of your medical license, or certification under your new name.

b. Changing the legal name associated with your Tax ID? See Additional Requirements below.

2. Email, fax, or mail the completed L&I forms to:

• PACMail@Lni.wa.gov
• Fax: 360-902-4563
• Provider Accounts and Credentialing
  PO Box 44261
  Olympia, WA 98504-4261

Additional Requirements

Providers must submit forms directly to the Office of Financial Management (OFM) for the following changes:

• Enrollment/changes in EFT payments.
• Legal name changes.

OFM forms can be found by following the link: ofm.wa.gov/payee

Note: L&I cannot accept or forward OFM forms on behalf of the provider.

For questions regarding OFM forms or the registration process, call 360-407-8180 or email: PayeeRegistration@ofm.wa.gov

Questions? Contact LNIProviderOne@Lni.wa.gov. We’ll respond to your email within three business days.

For Existing NPI changes, complete the Provider Account Change Form under your current Tax ID and submit with an updated W-9.

New Tax ID or Organization NPI

Changing your Tax ID or adding a new Organization NPI requires submitting a new application. Visit Become a Provider for instructions.

Approved network providers (Washington state MD, DO, DC, DDS, DPM, ND, OD, ARNP, and PA) not previously credentialed through a delegated group should submit the following:

1. Add Group Packet (F245-449-000)
2. Copy of your new Insurance Certificate
3. Complete the Provider Account Change Form (F245-365-000) to inactivate your current account(s), if you are no longer billing under your existing account, clinic, or group. When inactivating a clinic or group, this inactivates all providers in the group.

Fax or email the completed forms to:

                Fax: 360-902-4563

                Email: PACMail@Lni.wa.gov

For address or business status changes, complete the Approved IME Examiner Update form (F245-051-000).

If your clinic is setting up under a new Tax ID (EIN) or Organization NPI, go to Independent Medical Exams and submit a new application.

Note: OFM forms must be submitted at the same time as your Independent Medical Examiner Application to avoid potential delays in payment.

OFM forms can be found here: ofm.wa.gov/payee

Note: Providers are responsible for directly submitting necessary forms to OFM. L&I cannot accept or forward OFM forms on behalf of the provider.

For questions regarding OFM forms or the registration process, call 360-407-8180 or email: PayeeRegistration@ofm.wa.gov

Submit all forms to:
Fax: 360-902-4249
Mail: Provider Quality & Compliance
P O Box 44322
Olympia WA 98504-4322