Out of Country Provider Application

Out of Country Provider Application - (Forms/Publications)
Document Information
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Title Out of Country Provider Application (A fillable form - 235 KB PDF)
Description

This application is for providers outside the United States. Providers who treat injured workers must have a provider number to bill the department.

Detail
Form number F248-361-000
Availability
Online only. See document above to download.
Keywords doctor, medical provider, out of country, physician, physician assistant, provider, provider application
Languages English , Spanish
Valid dates 12-2013
Contact information Claims and Insurance

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