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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 Diary  F245-444-000 (English)
Activity Prescription Form (APF)  F242-385-000 (English)
Application to Reopen Claim Due to Worsening Condition  F242-079-909 (English/Spanish)
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)
Example Only  F999-999-000 (English)
Exception to Three-Day Limit of Opioids for Dental Procedures Prior Authorization Request  F252-118-000 (English)
Functional Capacity Summary  F245-434-000 (English)
Functional Recovery Interventions (RFI) Tracking Sheet  F245-420-000 (English)
Hearing Impairment Calculation Worksheet  F252-007-000 (English)
Hearing Services Worker Information  F245-049-000 (English)
Helpful Tips for Medical Services Providers  F248-040-000 (English)
How to Bill for an Occupational Disease History Report (Code 1055M)  F242-432-000 (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)
 F245-346-214 (Cambodian)
 F245-346-255 (Korean)
 F245-346-294 (Russian)
 F245-346-319 (Vietnamese)
 F245-346-221 (Chinese Traditional)
Labor and Industries Prosthetic Device Request Form  F245-340-000 (English)
Lyrica (pregabalin) Prior Authorizatin Request Form  F252-119-000 (English)
Medical Examiners' Handbook  F252-001-000 (English)
Medical Payment Guidance  F248-366-000 (English)
Negative Pressure Wound Therapy  F252-114-000 (English)
Notice of Occupational Disease or Infection  F242-243-000 (English)
Nurse Case Management Initial Care Management Plan  F245-442-000 (English)
Nurse Case Management Progress Report  F245-439-000 (English)
Nurse Case Management Qualis Progress Report  F245-441-000 (English)
Occupational Disease Claims in Workers' Compensation  F252-117-000 (English)
Out of Country Provider Account Application  F248-361-232 (French)
 F248-361-236 (German)
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)
Quick Reference Card for Providers 2017  F245-414-000_2017 (English)
Quick Reference Card for Providers 2018  F245-414-000_2018 (English)
Quick Reference Card for Providers 2019  F245-414-000_2019 (English)
Residential Care Assessment Tool  F245-377-000 (English)
Self-Insured Employers' Time Loss Claim Closure Order and Notice  F207-070-999 (Spanish)
Statement for Miscellaneous Services  F245-072-000 (English)
 F245-072-221 (Chinese Traditional)
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)
Tips for completing the Activity Prescription Form  F242-436-000 (English)
Transfer of Care  F245-037-000 (English)
 F245-037-214 (Cambodian)
 F245-037-255 (Korean)
 F245-037-294 (Russian)
 F245-037-999 (Spanish)
 F245-037-319 (Vietnamese)
 F245-037-220 (Chinese Simplified)
 F245-037-221 (Chinese Traditional)
 F245-037-218 (Chuukese)
 F245-037-233 (Farsi/Persian)
 F245-037-249 (Japanese)
 F245-037-291 (Punjabi/Panjabi)
 F245-037-303 (Somali)
 F245-037-307 (Tagalog/Filipino)
Vocational Training Plan Ownership Agreement for Tools and Equipment  F245-351-000 (English)
VRC Primary Contact Form  F252-105-000 (English)
Your Independent Medical Exam  F245-224-000 (English)
 F245-224-214 (Cambodian)
 F245-224-255 (Korean)
 F245-224-294 (Russian)
 F245-224-319 (Vietnamese)
 F245-224-200 (Albanian)
 F245-224-201 (Amharic)
 F245-224-203 (Arabic)
 F245-224-204 (Armenian)
 F245-224-211 (Bosnian)
 F245-224-212 (Bulgarian)
 F245-224-213 (Burmese)
 F245-224-220 (Chinese Simplified)
 F245-224-221 (Chinese Traditional)
 F245-224-218 (Chuukese)
 F245-224-223 (Croatian)
 F245-224-226 (Dari)
 F245-224-233 (Farsi/Persian)
 F245-224-232 (French)
 F245-224-242 (Hindi)
 F245-244-243 (Hmong)
 F245-224-243 (Hmong)
 F245-224-328 (Isoko)
 F245-224-249 (Japanese)
 F245-224-250 (Karen)
 F245-224-257 (Kurdish)
 F245-224-261 (Laotian)
 F245-224-272 (Marshallese)
 F245-224-274 (Mien)
 F245-224-280 (Nepali/Nepalese)
 F245-224-289 (Polish)
 F245-224-290 (Portuguese)
 F245-224-291 (Punjabi/Panjabi)
 F245-224-293 (Romanian)
 F245-224-297 (Samoan)
 F245-224-298 (Serbian)
 F245-224-303 (Somali)
 F245-224-304 (Soninke/Soninkeh)
 F245-224-305 (Swahili)
 F245-224-307 (Tagalog/Filipino)
 F245-224-338 (Tamil)
 F245-224-310 (Thai)
 F245-224-312 (Tigrinya/Tigrigna)
 F245-224-315 (Turkish)
 F245-224-316 (Ukrainian)
 F245-224-317 (Urdu)





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