Provider's Request for Adjustment

Document Information
  How to complete a fillable form.
Title Provider's Request for Adjustment

Providers use this to report total overpayment, partial overpayment and/or underpayment by L&I.

Document number F245-183-000
How to get this document
  • Order it from our Warehouse
  • Alt Language(s)
    Valid dates 01/2014, 11/2013
    Contact information Managing Injured Workers' Claims
    Websites For Medical Providers

    End of main content, page footer follows.

    Access Washington official state portal

      © Washington State Dept. of Labor & Industries. Use of this site is subject to the laws of the state of Washington.