Non-Network Provider Application

Document Information
  How to complete a fillable form.
Title Non-Network Provider Application

Includes the F248-036-000 Statewide Payee Registration and W-9 form. For providers to complete that do not want to become a Labor and Industries network provider, or for a specialty that L&I is not accepting network applications for at this time. If you are applying to be a Labor and Industries network provider, please complete application process at

Document number F248-011-000
How to get this document
Alt Language(s)
Valid dates 01/2013
Contact information
Websites For Medical Providers

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