Provider Account Application - Independent Medical Examiner (IME)
See also
| Document Information | ||
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 Get help downloading & printing files.  How to complete a fillable form. |
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| Title |
Provider Account Application - Independent Medical Examiner (IME) (A fillable form - 841 KB PDF)
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| Description | In order to do independent medical exams a provider must obtain a provider account number with L&I. This packet includes the application and agreement with instructions, IME Provider Exam sites form (F245-047-000) and Request for Taxpayer ID and Certification - Form W-9 (F248-036-000) (10 pages). If you have questions, please email balk235@lni.wa.gov or call 360-902-6815. |
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| Detail | ||
| Form number | F245-046-000 | |
| Availability | Online only. See document above to download. |
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| Keywords | doctor, exams, medical, most requested forms, physician, provider application, reapplication | |
| Languages | English | |
| Valid dates | 02-2013 | |
| Contact information |
Independent Medical Examiners
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| Related information | ||
| Documents | Independent Medical Examination (IME) Provider Exam Sites Statewide Payee Registration and W-9 Form |
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| Web pages | For Medical Providers | |
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