Non-Network Provider Application
See also
| Document Information | ||
|---|---|---|
 Get help downloading & printing files.  How to complete a fillable form. |
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| Title |
Non-Network Provider Application (A fillable form - 517 KB PDF)
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| Description | 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 www.ProviderNetwork.Lni.wa.gov |
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| Detail | ||
| Form number | F248-011-000 | |
| Availability | Order it |
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| Keywords | crime victim provider, doctor, interpreter, medical provider, most requested forms, physician assistant, provider application | |
| Languages | English | |
| Valid dates | 01-2013 | |
| Contact information | ||
| Web pages | For Medical Providers | |
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