Please report changes to your account within 14 calendar days.
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 changes, including billing staff and staff at individual clinic locations.
Select one of the following options, based upon the type of change to be made:
-
For address, name, account closures or other changes, to your:
Provider AccountProviders must submit:
- Provider Change Form, and
- Statewide Payee Registration form - needed for address or DBA and legal name changes only.
Note: 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.
Facility or hospital changes please include a copy of your medical license or certification under your new name.
IMPORTANT: For Account closures, you will need to submit the Provider change form only to inactivate your account. If we do not receive your request, your account will remain active in our system and on our website in Find a Doctor.
Fax or mail all documents to:
| Fax: | Mail: |
| Provider Account: 360-902-4484 Provider Network: 360-902-4563 |
Provider Credentialing PO Box 44261 Olympia, WA 98504-4261 |
Independent Medical Examiner (IME) AccountYour address or business status changes, notify us using the Approved IME Examiner Update form.
| Fax: | Mail: |
| IME Examiners: 360-902-4249 | Provider Quality & Compliance PO Box 44322 Olympia WA 98504-4322 |
-
For Tax ID (EIN or SSN) or Organization NPI changes, select one of the following:
Network Provider (Washington state MD, DO, DC, DDS, DPM, ND, OD, ARNP and PA)If your clinic is setting up under a new Tax ID (EIN or SSN) or Organization NPI, follow these steps:
You must submit the following for each provider in your clinic or group:
- Add Group Packet
- Copy of your new Insurance Certificate.
- Complete the Provider Account Change Form to inactivate your current account, if you are no longer billing under your existing account, clinic or group.
Note: When inactivating a clinic or group, this inactivates all providers in the group.
| Fax: | Mail: |
| 360-902-4563 | Provider Credentialing PO Box 44261 Olympia, WA 98504-4261 |
All Other Provider Types (in Washington state and all out of state providers)Individual Providers and Facilities (i.e. hospital, taxi, nursing homes, home modifications)
You will need to complete the following for each provider in your clinic or your facility:
- Provider Account Application.
- Attach a copy of your medical license and/or certification.
- Fulfill additional requirements if you are one of the following provider types: Interpreter, PGAP® Activity Coach, Vocational provider or Work-hardening provider.
- Complete the Provider Account Change Formto inactivate your current account, if you are no longer billing under your existing account, clinic or group.
Note: When inactivating a clinic or group, this inactivates all providers in the group.
| Fax: | Mail: |
| 360-902-4484 | Provider Credentialing PO Box 44261 Olympia, WA 98504-4261 |
Independent Medical ExaminerIf your clinic is setting up under a new Tax ID (EIN) or Organization NPI, complete the following:
Update your IME Provider Account Application and submit your new Statewide Payee Registration form.
| Fax: | Mail: |
| 360-902-4249 | Provider Qualtiy and Compliance PO Box 44322 Olympia, WA 98504-4322 |
Questions?
Provider Network questions, email: ProvNet@Lni.wa.gov
Provider Account questions, email: PACMail@Lni.wa.gov
