Get a Form or Publication: reimbursement

Your search for "reimbursement" returned 31 documents.

Title Type Number
Complete Stay at Work Guide for Employers, The

Booklet: Explains Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Provides information on reimbursements, what is covered and how to apply. Detailed Q&A section included.

Publication F243-005-000
Option 2 Vocational Benefits Training Enrollment Application and Verification
Also available in: English/Spanish

State fund workers who have selected Option 2 and closed their claim can use this form to apply for access to their Option 2 training funds. To seek reimbursement, use form F245-030-000 Statement for Retraining and Job Modification Services.

Form F280-024-000
Overpayment Reimbursement Fund Request Coversheet

This form is a coversheet used by Self-Insurance for overpayment reimbursement fund requests.

Form F207-212-000
Statement for Crime Victim Miscellaneous Services

Used by the provider or supplier for reimbursement of the following services - dental, glasses, home health, nursing home serivces, medical equipment, prosthetics-orthotics, transportation, vocational, retraining and other.

Form F800-076-000
Statement for Pharmacy Services

Bill form for prescription charges. May be used by a pharmacy to submit drug charges, or by a worker to request reimbursement for prescriptions paid out of pocket. See the General Provider Billing Manual (F248-100-000) for information on completing this form.

Form F245-100-000
Stay at Work: A new program to help employers keep injured workers on the job--pays half the wage plus expenses (Programa permanezca en el trabajo - Un nuevo programa para ayudar a los empleadores a mantener a los trabajadores lesionados en el trabajo
Also available in: English

Pamphlet/booklet: Provides an overview Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Includes information on eligibility, how to apply, and where to get more information.

Publication F243-006-999
Stay at Work: A new program to help employers keep injured workers on the job--pays half the wage plus expenses
Also available in: Spanish

Pamphlet/booklet: Provides an overview Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Includes information on eligibility, how to apply, and where to get more information.

Publication F243-006-000
Transportation Cost Encumbrance

To record the costs for transportation. For use only with plans approved after 1/1/2008.

Form F245-375-000
Travel Reimbursement Request - Spanish Solicitud para el reembolso de gastos de viaje
Also available in: English

Injured workers use this form to request reimbursement for travel expenses used to receive treatment, retraining and/or vocational services.

Form F245-145-999
Travel Reimbursement Request
Also available in: Spanish

Bill form for use by workers to request reimbursement for authorized travel expenses.

Form F245-145-000
Cholinesterase Monitoring Reimbursement Request

Employers use this form to request reimbursement for the reasonable costs of training, travel, recordkeeping, and medical expenses for Cholinesterase Monitoring.

Form F413-062-000
CMS 1500 (formerly L&I Health Insurance Claim form)

Used by providers to be reimbursed for services. It is NOT for use by injured workers to submit a claim to L&I.

Form F245-127-000
Helping Providers Understand the Crime Victims Compensation Program

Fact sheet: Answers questions doctors and mental health counselors may have about the Crime Victims Compensation Program and billing for services. Also suggests steps these providers can take to speed up reimbursement.

Publication F800-102-000
Instructions in Spanish for completing the form F245-072-000 Statement for Miscellaneous Services
Also available in: English

Instructions in Spanish for completing the form F245-072-000 Statement for Miscellaneous Services

Form F245-072-999
L&I Toolkit for Providers and Billing

CD: Includes informational materials for new providers. Also contains the rules and policies for reimbursing medical services and lists maximum fees. This CD was previously titled Medical Aid Rules and Fee Schedules. To access the fee schedules, see the "Fee Schedules" Web page listed on the full description page for this publication.

CD F245-094-034
Option 2 Vocational Benefits Training Enrollment Application/Aplicación y verificación del registro(English/Spanish)
Also available in: English

State fund workers who have selected Option 2 and closed their claim can use this form to apply for access to their Option 2 training funds. To seek reimbursement, use form F245-030-000 Statement for Retraining and Job Modification Services.

Form F280-024-909
Social Security Offset Calculations Only Quarterly Statement of Supplemental Benefits Paid for Self-Insured Employers

Used by self-insured employers to request reimbursement from L&I for cost-of-living-adjustments paid to injured workers.

Form F207-011-222
Statement for Compound Prescription

Bill form for use by pharmacies and home infusion companies to submit compound drug charges. This form is for drug charges only, and is filled out by the pharmacist. See the Pharmacy Billing Instructions (F248-021-000) for information on completing this form.

Form F245-010-000
Statement for Crime Victims Mental Health Services

Used by the Crime Victims Compensation Program providers for reimbursement of Mental Health Services.

Form F800-025-000
Statement for Home Nursing Services

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

Form F248-160-000
Statement for Home Nursing Services - Crime Victims

Used by the Crime Victims Compensation Program providers for reimbursement of home nursing services. Crime Victims Compensation Program providers are required to bill using this form.

Form F800-070-000
Statement for Pharmacy Services - Crime Victims

Used by Crime Victims Compensation Program providers to bill for pharmacy services. Crime Victims Compensation Program providers are required to bill using this form.

Form F800-058-000
Statement for Retraining and Job Modification Services

Bill form for providers that bill the department for claim-related retraining and job modification services. See the Retraining and Job Modification Billing Instructions (F248-015-000) for information on completing this form.

Form F245-030-000
Stay at Work Expense Reimbursement Application for Employers Tools, Clothing, Training.

Employer of record can request reimbursement for tools, clothing, or training expenses required to enable an injured worker to return to light duty or transitional work. After completing the form, the employer submits it, along with supporting documentation, to the Stay at Work program for review and approval. For wage reimbursements see F243-001-000.

Form F243-003-000
Stay at Work Wage Reimbursement Application for Employers

Employer of record can request reimbursement for wages paid to an injured worker during light duty or transitional work. After completing the form, the employer submits it, along with supporting documentation, to the Stay at Work program for review and approval. For expense reimbursements see F243-003-000.

Form F243-001-000
Travel Reimbursement Request - Crime Victims

If you are considered a victim of crime, use this form to track your travel expenses for medical, retraining or vocational services or for an independent medical exam. You should have approval from your claim manager before you travel.

Form F800-049-000
Your Independent Medical Exam
Also available in: Spanish

Pamphlet/booklet: Answers the most common questions about independent medical exams and when and why an injured worker may be required to receive one. Includes the "IME Travel & Wage Reimbursement Request" form.

Form, Publication F245-224-000
Your Independent Medical Exam (IME)/Su Examen Médico Independiente (Spanish)
Also available in: English

Pamphlet/booklet: Answers the most common questions about independent medical exams and when and why an injured worker may be required to receive one. Includes the "IME Travel & Wage Reimbursement Request" form.

Form, Publication F245-224-999
Your Independent Medical Exam (IME): Crime Victims Compensation Program

Fact Sheet: Provides answers to commonly asked questions about independent medical exams (IMEs) and contact information. Includes a form for requesting travel-related reimbursement for attending an IME.

Publication F800-115-000
Your Independent Medical Exam: For Employees of Self-Insured Businesses
Also available in: Spanish

Pamphlet: Answers the most common questions about when and why an injured worker may be required to attend an independent medical exam. Includes the "IME Travel & Wage Reimbursement Request" form. This publication is for use only by self-insured businesses and their workers.

Publication F207-202-000
Your Independent Medical Exam: For Employees of Self-Insured Businesses - Spanish (Su Examen Médico Independiente: Para empleadores de negocios autoasegurados)
Also available in: English

Pamphlet: Answers the most common questions about when and why an injured worker may be required to attend an independent medical exam. Includes the "IME Travel & Wage Reimbursement Request" form. This publication is for use only by self-insured businesses and their workers.

Publication F207-202-999

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