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Self-Insurance Medical Provider Billing Dispute form

A form for Providers to submit disputes to the department regarding payment of medical provider bills

3 Things to Know about L&I's Medical Provider Network

Handout: Explains to workers the basic information about L&I’s Medical Provider Network. The handout can be used with workers covered both by L&I and by self-insured employers. Applies to workers in Washington state. Includes website and phone number contact information.


Otro(s) idioma(s):
Provider's Initial Report (PIR)

Used by medical providers when reporting initial treatment for an industrial injury or occupational disease for a self-insured claim.

Medical providers treating self-insured workers, self-insured businesses, or their third party claims administrators can access this form one of two ways:

  1. Download the Microsoft (MS) Word form and the PDF file with instructions:

           The first file is the PDF instructions.

           The second file is an Office 2003 MSWord document ending in .doc.

           The third file is an Office 2007/2010 version, ending in .docx.

2.  Order paper copies of this form by clicking the “order it” button.

Report of Accident (ROA) Workplace Injury, Accident or Occupational Disease

This form is not available to download. If you are an injured worker, ask your medical provider for a copy of this form or you can complete your portion of the Report of Accident (ROA) online at www.FileFast.Lni.wa.gov. Please note only medical providers may order this form from the Warehouse.


Otro(s) idioma(s):
Notice of Occupational Disease or Infection

Used by medical providers to notify L&I that an occupational disease or infection has been diagnosed and that the worker has been advised that their condition may be work-related. This form can be used if the worker does not complete a Report of Accident or Occupational Disease (ROA) but should not be completed in place of an ROA.

Stay at Work Exam Room Card

Laminated Exam Room Card: gives medical providers talking points to share with injured workers about following prescribed light-duty and informs them about the benefits of the Stay at Work Program. 

Workers' Comp Fraud Hurts YOU
Pamphlet: Explains the impacts of workers' comp fraud and L&I's efforts to prevent and find fraud by workers, employers, contractors, and medical providers.

Recordkeeping and Reporting - WAC 296-27

These WAC and RCW rules explain the record keepkeeping responsibilities of businesses such as medical providers, employers who handle biohazards, etc.

Non-Network Provider Application

Includes the F248-036-000 Statewide Payee Registration and W-9 form. For providers to complete that do not want to become a Labor and Industries network provider, or for a specialty that L&I is not accepting network applications for at this time. If you are applying to be a Labor and Industries network provider, please complete application process at www.ProviderNetwork.Lni.wa.gov

Need a Doctor?

Information card: Provides contact information for injured workers needing assistance in finding a health-care provider who will treat their occupational injury or disease. This PDF will print out an 8.5" X 11" sheet that has 12 copies of the card. Note: Disclaimer information on Page 2 may not line up accurately in two-sided printing.


Otro(s) idioma(s):
Provider Network Agreement
The provider network agreement for participation in the health care provider network for injured workers covered by Washington State Fund and self-insured employers.

Out of Country Provider Application

This application is for providers outside the United States. Providers who treat injured workers must have a provider number to bill the department.


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