Used by self-insured employers to participate in the Orthopedic & Neurological Surgeon Quality Pilot

Book: This handbook contains useful information to help providers who treat patients in the workers' compensation system. The publication also includes a feature to assist physicians in attaining three hours of Category 1 CME credit by completing the exam at the end of the handbook. L&I and the authors have no financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this document.

Book: Discusses best practices in occupational medicine that help return an injured worker to his/her job as soon as medically possible. Identifies resources available from L&I and explains how to bill for return-to-work services. Three hours of Category 1 CME credit are offered for completing the test inside the handbook.

Book: Describes the responsibilities of the attending chiropractic physician in preventing claims problems.

Used by both workers and bidding contractors to read, sign and submit to L&I to verify that they have read, understand and accept their respective responsibilities in the home modification process.

Doctor's Worksheet for Rating Cervical and Cervico-Dorsal Impairment

This worksheet is to help the attending physician perform impairment rating on their patients with permanent partial disability of the Dorso-Lumbar or Lumbo-Sacral spine.

To authorize L&I to accept electronically submitted bills for services provided to injured workers (3 pages).

Used by providers to bill L&I for reimbursement.

Guide for Payroll Service Providers Bulk Filing Worker's Compensation Quarterly Reports

Used by the attending doctor to determine hearing loss.

Fact sheet: Answers questions about the home modification benefit in Washington State's workers' compensation program, who qualifies, what L&I can pay, and where to get more information.

Fact sheet: Answers questions about the home modification benefit in Washington State's workers' compensation program and the bid process for contractors interested in this work.

Fact sheet: Provides tips to help medical service providers quickly obtain answers to claims and billing questions. Introduces L&I's Provider Hotline, Interactive Voice Response Message System and online Claim & Account Center.

To change an individual's (service provider's) name, add or delete referral categories, update certifications, leaving a firm, intern supervisor changes, and/or adding or deleting a branch for referrals.

Pamphlet: Explains the importance of quality health care in the treatment of injured workers. Describes the services L&I offers health-care providers who treat injured workers, including provider account representatives who can answer questions and assist with complex billing issues.

Labor and Industries Prosthetic Device Request Form

You must mail or fax form. No emailed forms are accepted. This assessment tool is provided by L&I assessment to determine the medically appropriate level of care that will meet the Injured Worker’s needs, abilities and safety in a residential facility. This assessment is not intended as a substitute for DSHS annual assessment & treatment plan, which is the sole financial responsibility of the facility.

This form has a list of mailing addresses and document types a provider uses to send to L&I. There is also a list of phone numbers.

Used by a licensed massage practitioner/clinic to request authorization for outpatient massage therapy services for L&I claims.

This form is so L&I's Office of the Medical Director can evaluate medical device(s) that the attending physican wants to use to treat an injured worker.

Book: A publication for independent medical examiners, attending doctors and consultants, this document contains guidelines, sample reports and billing procedures for preparing and conducting impairment ratings and IMEs in Washington's workers' compensation system. The publication also includes a feature to assist physicians in attaining three hours of Category 1 CME credit by completing the self-assessment test at the end of the handbook. See also Self-Assessment Exam at www.Lni.wa.gov/IPUB/252-001-000Exam.pdf. L&I and the authors have no financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this document.

Used to order L&I medical forms.

This is an outdated book of medical treatment guidelines and is available for archival reference only. The current medical treatment guidelines can be found at http://www.lni.wa.gov/ClaimsIns/Providers/Treatment/TreatGuide/default.asp where each guideline has its own link and file.

Used by medical providers to notify L&I that an occupational disease or infection has been diagnosed and that the worker has been advised that their condition may be work-related. This form can be used if the worker does not complete a Report of Accident or Occupational Disease (ROA) but should not be completed in place of an ROA.

Used by a therapy provider/clinic to request authorization for outpatient occupational or physical therapy services for L&I claims.

Used by occupational and physical therapy providers as an optional reporting format for a Performance-based Physical Capacities Evaluation.

Providers complete this form to authorize a clearinghouse or third party to receive the EDI 835 Electronic Remittance Advice file from L&I's Provider Express Billing (PEB).

For use by a therapist or vocational provider to request job modification for an injured worker before the injured workers is employed, possibly in a retraining program. This may involve tools and equipment that is purchased through L&I.

For providers to apply for a provider account number with L&I. Includes the Form W-9 Request for Taxpayer ID Number and Certification (F248-036-000). 10-2009 version is internet only, not printed.

Used by providers (Orthopedic, Neurological and Hand Surgeons) to participate in the Orthopedic and Neurological Surgeon Quality Pilot.

Used by providers (PA-Cs, and ARNPs that work at a participating clinic) to participate in the Orthopedic and Neurological Surgeon Quality Pilot.

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.

This form is to be used by Spanish speaking Medical Providers out side the United States. . This form now includes both English and Spanish versions of the Provider form and letters. File includes W8ECI form from IRS and instructions for the form. Both IRS form and instructions are in English.This version is not the same as the English version, which is intended for use by Providers in the United States

Used by injured workers, doctors, and employers to report an industrial injury or occupational disease. This report is not available online. Order by the number of copies you need. Do not order by box or case. If you are an injured worker, ask your doctor for a copy of this form.

Use this form to obtain your taxpayer ID number.

Used by vocational counselors to test an injuried worker's skills and abilities.

Sample of a job offer letter from a business to an injured employee.

Sample of a letter a return to work person would use to assist L&I in determining whether services or funds should be authorized to assist them in becoming self-employed.

Used to bill L&I for reimbursement of home nursing services.

Used by the injured worker for reimbursment of expenses for retraining related to their worker's compensation claim. This form is signed by the injured worker and the provider.

Booklet/pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided.

Booklet/pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided.

Booklet/Pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided.

Booklet/Pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided.

Routing slip that accompanies the Vocational Services Closing Cover Sheet (F252-028-000) which is used to close vocational services to an injured worker.

Used to close vocational services of an injured worker. This form is attached to Vocational Closing Report Routing Sheets F280-013-000, F280-014-000 or F252-027-000.

Injured worker agrees to the ownership terms of the tools and/or equipment purchased as part of their training plan by L&I.

Pamphlet: Explains the impacts of workers' comp fraud and L&I's efforts to prevent and find fraud by workers, employers, contractors, and medical providers.