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Results for: Claims and Insurance - Medical Provider Claim Management
Title Number / Language
3 Things to Know about L&I's Medical Provider Network  F242-406-000 (English)
 F242-406-999 (Spanish)
Activity Prescription Form (APF)  F242-385-000 (English)
Attending Doctor's Handbook  F252-004-000 (English)
Attending Provider's Referral Form  F252-098-000 (English)
Attending Provider's Return-to-Work Desk Reference  F200-002-000 (English)
Buprenorphine Transdermal Patch Authorization Request Form  F252-110-000 (English)
Certificate of Coverage - SAMPLE ONLY  F211-141-999 (Spanish)
Common Errors on the Interpretive Services Appointment Record (ISAR)  F245-436-000 (English)
Doctor's Worksheet for Rating Cervical and Cervico-Dorsal Impairment  F252-056-000 (English)
Doctor's Worksheet for Rating Dorso-Lumbar & Lumbo-Sacral Impairment  F252-006-000 (English)
Functional Capacity Summary  F245-434-000 (English)
Functional Recovery Interventions Tracking Sheet  F245-420-000 (English)
Hearing Impairment Calculation Worksheet  F252-007-000 (English)
Hearing Services Worker Information  F245-049-000 (English)
Hotline Tips for Medical Services Providers  F248-040-000 (English)
Independent Medical Exam Doctor's Estimate of Physical Capacities  F242-387-000 (English)
Interpretive Services Appointment Record (ISAR)  F245-056-000 (English)
Job Modification Assistance Application  F245-346-000 (English)
Labor and Industries Prosthetic Device Request Form  F245-340-000 (English)
Long Term Care Assessment Tool  F245-377-000 (English)
Medical Examiners' Handbook  F252-001-000 (English)
Medical Payment Guidance  F248-366-000 (English)
Notice of Occupational Disease or Infection  F242-243-000 (English)
Out of Country Provider Application  F248-361-000 (English)
 F248-361-999 (Spanish)
Physical Therapy / Occupational Therapy Progress Report to Claim Managers  F245-059-000 (English)
Pre-Job Accommodation Assistance Application  F245-350-000 (English)
Preauthorization Request for Services for State Fund Workers' Compensation Patients  F242-397-000 (English)
Provider's Initial Report (PIR)  F207-028-000 (English)
Provider's Request for Adjustment  F245-183-000 (English)
PT/OT Referral Form  F252-099-000 (English)
Quick Reference Card for Providers 2016  F245-414-000_2016 (English)
Self-Insured Employers' Time Loss Claim Closure Order and Notice  F207-070-999 (Spanish)
Statement for Miscellaneous Services  F245-072-000 (English)
Statement for Retraining and Job Modification Services  F245-030-000 (English)
Submission of Provider Credentials for Interpretive Services  F245-055-000 (English)
Termination of Agreement (Rescission)  F245-050-000 (English)
Transfer of Care Card  F245-037-000 (English)
 F245-037-999 (Spanish)
Vocational Training Plan Ownership Agreement for Tools and Equipment  F245-351-000 (English)
Your Independent Medical Exam  F245-224-000 (English)





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