Provider Accounts Change Form


Provider Accounts Change Form

Document Information
Get help downloading & printing files. How to complete a fillable form.
Title	Provider Accounts Change Form (A fillable form - 389 KB PDF)
Description	Providers use this form to notify L&I of a change of their business address, billing address and account termination. Also has info on how to notify L&I on a tax ID (EIN) number change, tax ID address change and/or name change.
Detail
Form number	F245-365-000
Availability	Order it
Keywords
Languages	English
Valid dates	03-2009
Contact information	Managing Injured Workers' Claims Claims for Job Injuries
Web pages	For Medical Providers