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Attending Provider's Return-to-Work Desk Reference


Publicación
F200-002-000
 
Provider's Initial Report (PIR)


Formulario
F207-028-000
 
Transfer of Attending Provider Form for Self Insured Workers


Formulario
F207-114-000

Otro(s) idioma(s):
Español
 
Self-Insurance Medical Provider Billing Dispute Form


Formulario
F207-207-000
 
3 Things to Know about L&I's Medical Provider Network


Publicación
F242-406-000

Otro(s) idioma(s):
Español
 
Provider Account Application - Independent Medical Examiner (IME)


Formulario
F245-046-000
 
Independent Medical Examination (IME) Provider Exam Sites


Formulario
F245-047-000
 
Submission of Provider Credentials for Interpretive Services


Formulario
F245-055-000
 
Provider's Request for Adjustment


Formulario
F245-183-000
 
Provider Payment Account Change Form


Formulario
F245-365-000
 
Provider Network Agreement


Formulario
F245-397-000
 
Quick Reference Card for Providers 2015


Publicación
F245-414-000_2015
 
Physical/Occupational/Massage Therapy Provider Hotline Service Authorization Request


Formulario
F245-417-000
 
Hearing Aid Repair/Durable Medical Equipment Provider Hotline Service Authorization Request


Formulario
F245-418-000
 
Provider General Billing Manual


Manual
F245-432-000
 
Non-Network Provider Application


Formulario
F248-011-000
 
Hotline Tips for Medical Services Providers


Publicación
F248-040-000
 
General Provider Billing Manual


Manual
F248-100-000
 
Payroll Service Provider - Quarterly Reporting Bulk Filing Enrollment Form


Formulario
F248-343-000
 
Out of Country Provider Application


Formulario
F248-361-000

Otro(s) idioma(s):
Español
 
Supplemental Agreement Third Party Pharmacy Provider


Formulario
F249-021-000
 
Individual Vocational Provider Account Change Form


Formulario
F252-021-000
 
Firm Vocational Provider Account Change


Formulario
F252-022-000
 
Vocational Provider Application


Formulario
F252-088-000
 
On-The-Job Training (OJT) Agreement for Vocational Providers


Formulario
F280-039-000
 
Non-accredited or Unlicensed Training Provider Application Supplemental Requirements


Formulario
F280-045-000
 
Cholinesterase Monitoring Health Care Provider Recommendations


Formulario
F413-070-000

Otro(s) idioma(s):
Español
Español
 
Elevator Continuing Education Provider / Instructor Application


Formulario
F621-078-000
 
Master Level Counselor Provider Account Application for Crime Victims


Formulario
F800-053-000
 
Crime Victims Provider's Request for Adjustment


Formulario
F800-064-000
 
Provider Change Form for Crime Victims Compensation


Formulario
F800-089-000
 
Helping Providers Understand the Crime Victims Compensation Program


Publicación
F800-102-000
 
Need a Doctor?


Publicación
F160-006-000

Otro(s) idioma(s):
Español
 
Application to Reopen Claim Due to Worsening Condition


Formulario
F242-079-000

Otro(s) idioma(s):
Inglés/Español
Español
 
Report of Accident (ROA) Workplace Injury, Accident or Occupational Disease


Formulario
F242-130-000

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


Formulario
F242-243-000
 
Activity Prescription Form (APF)


Formulario
F242-385-000
 
Preauthorization Request for Services for State Fund Workers' Compensation Patients


Formulario
F242-397-000
 
Resume Cover Sheet


Formulario
F242-418-000
 
Stay at Work Exam Room Card


Publicación
F243-009-000
 
Performance Based Physical Capacities Evaluation


Formulario
F245-023-000
 
Statement for Retraining and Job Modification Services


Formulario
F245-030-000

Otro(s) idioma(s):
Español
 
Statement for Miscellaneous Services


Formulario
F245-072-000

Otro(s) idioma(s):
Español
 
Statement for Pharmacy Services


Formulario
F245-100-000
 
CMS 1500


Formulario
F245-127-000
 
Pre-Job Accommodation Assistance Application


Formulario
F245-350-000
 
F245-392-000 Resource Utilization Group (RUG) Residential Care Services for L&I Injured Workers (In place of MDS 3.0 beginning October 1, 2010.)


Formulario
F245-392-000
 
Pharmacy Companion Guide


Manual
F245-400-000
 
Washington Practitioner Application


Formulario
F245-411-000
 
Functional Recovery Interventions Tracking Sheet


Publicación
F245-420-000
 
CMS 1500 Billing Manual


Manual
F245-423-000
 
Home Health Services Billing Manual


Manual
F245-424-000
 
Miscellaneous Services Billing Manual


Manual
F245-431-000
 
Power of Attorney for Electronic Remittance Advice


Formulario
F248-355-000
 
Medical Payment Guidance


Publicación
F248-366-000
 
Medical Examiners' Handbook


Publicación
F252-001-000
 
Attending Doctor's Handbook


Publicación
F252-004-000
 
Workers' Comp Fraud Hurts YOU


Publicación
F262-279-000
 
Vocational Questionnaire/Work History


Formulario
F280-038-000

Otro(s) idioma(s):
Español
 
Referral to Labor and Industries /WorkSource Partnership Services


Formulario
F280-046-000
 
Recordkeeping and Reporting - WAC 296-27


Manual
F414-037-000
 
Statement for Crime Victims Mental Health Services


Formulario
F800-025-000
 
Application to Reopen Crime Victim Claim Due to Worsening of Condition


Formulario
F800-031-000

Otro(s) idioma(s):
Español
 
Crime Victims Statement for Pharmacy Services


Formulario
F800-058-000
 
Statewide Payee Registration and W-9 Form Crime Victims


Formulario
F800-065-000
 
Crime Victims Statement for Home Nursing Services


Formulario
F800-070-000
 
Statement for Crime Victim Miscellaneous Services


Formulario
F800-076-000
 
Crime Victims Compensation Program Initial Response and Assessment: Form I


Formulario
F800-080-000
 
Crime Victims Compensation Program Initial Response and Assessment: Form II


Formulario
F800-081-000
 
Crime Victims Compensation Program Progress Note: Form III


Formulario
F800-082-000
 
Crime Victims Compensation Program Treatment Report: Form IV


Formulario
F800-083-000
 
Crime Victims Compensation Program Treatment Report: Form V


Formulario
F800-084-000
 
Crime Victims Compensation Program Termination Report: Form VI


Formulario
F800-085-000
 
Billing Guidelines for Sexual Assault Examinations: Crime Victims Compensation Program


Manual
F800-100-000
 
Mental Health Fee Schedule and Billing Guidelines


Manual
F800-105-000
 
Crime Victims Direct Entry Billing Manual


Manual
F800-118-000
 
Self-Insurance Vocational Services Closing Cover Sheet


Formulario
F207-171-000
 
Transfer of Care Card


Formulario
F245-037-000

Otro(s) idioma(s):
Español
 
Tarjeta para transferencia de caso


Formulario
F245-037-999

Otro(s) idioma(s):
Inglés
 
Travel Reimbursement Request


Formulario
F245-145-000

Otro(s) idioma(s):
Español
 
Job Modification Assistance Application


Formulario
F245-346-000

Otro(s) idioma(s):
Español
 
Vocational Training Plan Ownership Agreement for Tools and Equipment


Formulario
F245-351-000

Otro(s) idioma(s):
Español
 
Electronic Billing Authorization


Formulario
F248-031-000
 
Statewide Payee Registration and W-9 Form


Formulario
F248-036-000
 
Medical Device Review Request


Formulario
F252-013-000
 
Sample Format for Vocational Testing Report


Formulario
F252-051-000
 
Sample Format for Vocational Evaluation Testing Plan


Formulario
F252-052-000
 
Crime Victim Compensation Program Sexual Assault Exam Report


Formulario
F800-098-000
 
Self-Insurance Vocational Reporting Form


Formulario
F207-190-000
 
Plan Room and Board Cost Encumbrance


Formulario
F245-372-000
 
Training Plan Cost Encumbrance


Formulario
F245-374-000
 
Transportation Cost Encumbrance


Formulario
F245-375-000
 
Time Encumbrance Form


Formulario
F245-376-000
 
Plan Development Quality Assurance Review Form


Formulario
F280-007-000
 
Assessment Eligible Quality Assurance Review Form


Formulario
F280-008-000
 
Carrying Out Your Vocational Plan: Your Rights and Responsibilities During Plan Implementation


Publicación
F280-019-000

Otro(s) idioma(s):
Español
 
Option 2 Vocational Benefits Training Enrollment Application and Verification


Formulario
F280-024-000

Otro(s) idioma(s):
Inglés/Español
 
Option 2 Vocational Benefits Training Enrollment Application/Solicitud y verificación del registro para capacitación de beneficios vocacionales opción 2 (English/español)


Formulario
F280-024-909

Otro(s) idioma(s):
Inglés
 
OJT Information Request and Recommendation form


Formulario
F280-032-000
 
Cuestionario Vocacional/Historia de trabajo


Formulario
F280-038-999
 
WISHA Occupational Exposure to Bloodborne Pathogens - Chapter 296-823 WAC


Manual
F414-073-000
 
Formulario para trasferencia de proveedor principal para trabajadores autoasegurados


Formulario
F207-114-999

Otro(s) idioma(s):
Inglés
 
Overpayment Reimbursement Fund Request Coversheet


Formulario
F207-212-000
 
Tres cosas que debe conocer sobre la Red de proveedores médicos de L&I


Publicación
F242-406-999

Otro(s) idioma(s):
Inglés
 
Crime Victims' Statement for Compound Prescription


Formulario
F800-067-000
 





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