Note: The October 2012 update edition contains limited new information, including a summary of recent workers' compensation reforms. The inside pages remain the same as the 03-2005 edition. This handbook contains useful information to help providers who treat patients in the workers' compensation system. Physicians can obtain 3 hours of CE credit by completing an online self-assessment based on this handbook. L&I and the authors have no financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this document.

Book: A publication for independent medical examiners, attending doctors and consultants, this document contains guidelines, sample reports and billing procedures for preparing and conducting impairment ratings and independent medical exams in Washington's workers' compensation system. Beginning July 1, 2012, free Category I CME credits are available for completing the self-assessment associated with this handbook. Go to www.Imes.Lni.wa.gov and click on Medical Examiners Handbook for information on the exam. L&I and the authors have no financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this document.

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

When prescribing opioids for chronic, noncancer pain; the attending physician must submit this form, or an equivalent form at least every 60 days. Providers are encouraged to submit after each visit.

In order to do independent medical exams a provider must obtain a provider account number with L&I. This packet includes the application and agreement with instructions, IME Provider Exam sites form (F245-047-000) and Request for Taxpayer ID and Certification - Form W-9 (F248-036-000) (10 pages). If you have questions, please email balk235@lni.wa.gov or call 360-902-6815.

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.

Use this form to submit your taxpayer ID number. Note: Register now for direct deposit available at a later date.

This form is used by self-insured injured workers who want to transfer their medical care.  Self-insured workers should complete the form and send it to their employer or their Third Party Representative

Este formulario es utilizado por los trabajadores autoasegurados que desean transferir su cuidado mdico. Los trabajadores autoasegurados deben completar este formulario y enviarlo a su empleador o a su Representante de Terceros.

Used by injured worker to notify claim manager and request authorization to transfer care to a different doctor. Do it online! Use the online Transfer of Care

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

To update or correct the IME's contact, availability, qualificaitons and/or exam sites.

Book: Discusses best practices in occupational medicine that help return an injured worker to his/her job as soon as medically possible. Identifies resources available from L&I and explains how to bill for return-to-work services. Three hours of Category 1 CME credit are offered for completing an online self-assessment. Go to www.CMECredits.Lni.wa.gov.

Filled out by the provider. This form gives the recommendations by the provider of what needs to be done based on the test results on the employee.

Used by the injured worker to provide comments to L&I about their recent medical exam by an IME.

The attending doctor refers an injured worker for consultation for clinical issues, 120 day consultation and/or closing, etc.

A form used by physicians, hospitals and clinics to provide information and reporting to the Crime Victims Compensation Program.

This worksheet is to help the attending physician perform impairment rating on their patients with permanent partial disability of the Dorso-Lumbar or Lumbo-Sacral spine.

Fact sheet: Provides tips to help medical service providers quickly obtain answers to claims and billing questions. Introduces L&I's Provider Hotline, Interactive Voice Response Message System and online Claim & Account Center.

Used by the injured worker to provide comments to L&I about their recent medical exam by an IME.

List the locations where the doctor does independent medical exams on a regular basis.

This form is so L&I's Office of the Medical Director can evaluate medical device(s) that the attending physican wants to use to treat an injured worker.

Filled out by the provider. This form gives the recommendations by the provider of what needs to be done based on the test results on the employee.

A notice to the attending physician that the individual is a Registered Apprentice and to attach this form to the Accident Report of Industry Injury or Occupational Disease (F242-130-000).

This form is used by applicants applying for a charter boat operators license to have completed by a physician for an operators license

This form is to be used by Spanish speaking Medical Providers outside the United States. This form now includes both English and Spanish versions of the Provider form and letters. File includes W8ECI form from IRS and instructions for the form. Both IRS form and instructions are in English. Instructions in Spansih for the W8ECI have been added. This version is not the same as the English version, which is intended for use by Providers in the United States.

The provider network agreement for participation in the health care provider network for injured workers covered by Washington State Fund and self-insured employers.

Used by injured worker to notify claim manager and request authorization to transfer care to a different doctor.