Obtenga un formulario o publicación: Change form
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| Título | Tipo | Número |
|---|---|---|
Individual Vocational Provider Account Change Form To change an individual's (service provider's) name, add or delete referral categories, update certifications, leaving a firm, intern supervisor changes, and/or adding or deleting a branch for referrals. |
Form | F252-021-000 |
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 |
| Provider Change Form for Crime Victims Compensation
Providers use to inform L&I that they have changes to their account. Such as changes to their Tax ID address/name, business address, billing address, name, or termination of account. This also includes a W-9 form. |
Form | F800-089-000 |
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