Get a Form or Publication: Provider Credentialing
Your search for "Provider Credentialing" returned 2 documents.
See also
| Title | Type | Number |
|---|---|---|
| Provider Credentialing Change Form
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. |
Form | F245-365-000 |
| Statewide Payee Registration and W-9 Form
Use this form to submit your taxpayer ID number. Note: Register now for direct deposit available at a later date. |
Form | F248-036-000 |
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