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Independent Medical Examination Fax Cover Sheet
Independent Medical Examination Fax Cover Sheet

Form
F245-383-000
 
Hearing Aid Repair Authorization Fax Request

Hearing Aid Repair Authorization Requests. If you need to purchase or replace a hearing aid, fax all of the information required by Medical Aid Rules and Fee Schedule (MARFS) including the Hearing Services Worker Information (F245-049-000) to 360-902-6252.



Form
F245-384-000
 
Occupational or Physical Therapy Treatment Authorization Fax Request

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



Form
F248-055-000
 
Massage Therapy Treatment Authorization Fax Request

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



Form
F248-357-000
 
Interpretive Services Appointment Record

This form is used when an interpreter is appointed to interpret for an injured worker during their medical visits.

When ordering, there is a limit of 4 pads, or 100 copies total. Fax your request to the L&I Warehouse at 360-902-4525 or email whsemail@Lni.wa.gov   Include the following in your request: Your name, mailing address, and telephone number and form number F245-056-000.



Form
F245-056-000
 
Long Term Care Assessment Tool

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.



Form
F245-377-000
 
Non-Compliance Report - Boiler & Pressure Vessel Inspection
Used by L&I inspectors when a boiler or pressure vessel does not pass inspection. You can only mail or fax this form to L&I. E-mailed forms are NOT accepted.

Form
F620-012-000
 
Application for Certificate of Competency as an Inspector of Pressure Retaining Items
To apply for a certificate of competency as an Inspector of Pressure Retaining items. You can only mail or fax this form to L&I. Emailed forms are not accepted. NOTE: Applications MUST be received no later than 30 days prior to the exam date. Incomplete applications WILL NOT be accepted.

Form
F620-040-000
 
Boiler/Pressure Vessel Clearance Variance Request
To request a clearance variance on a boiler or pressure vessel. You can only mail or fax this form to L&I. E-mailed forms are not accepted.

Form
F620-041-000
 
Contractor Registration Request for Duplicate License or Address Change  

This form may be faxed to the Contractor Registration office in Tumwater.



Form
F625-108-000
 
Seasonal Group Variance Application

Used for Exceptions from the Hours of Work for Minors for Seasonal work.  Complete the form, print it, sign it and fax or mail it to the address at the top of the form. Variance Application forms may be faxed to (360) 902-5300. If you would like the approved Variance Certificate faxed back to your business, please state so on your cover sheet.



Form
F700-135-000
 





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