Provider Account Application - Independent Medical Examiner (IME)

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Title Provider Account Application - Independent Medical Examiner (IME)

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 or call 360-902-6815.

Document number F245-046-000
How to get this document
Alt Language(s)
Valid dates 02/2013
Contact information Independent Medical Examiners
Related information

Independent Medical Examination (IME) Provider Exam Sites

Statewide Payee Registration and W-9 Form

Websites For Medical Providers

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