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

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 to apply as a interpretive service provider and to show what language(s) you hold credentials for. F248-011-000 Provider Application and Notice is added to this form.

Used by non-accredited or unlicensed training providers in order to be reviewed for approval to become a training provider for Washington injured workers. Must be submitted with the Provider Account Application (F248-011-000).

Complete this application and the StateWide Payee W-9 if you are applying for a firm Provider Number with L&I.

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.