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Termination of Agreement (Rescission)

To be filled out by the injured worker who wants to return hearing aids.



Formulario
F245-050-000
 
Approved Independent Medical Examiner (IME) Update

This document is used to update or correct an IME's contact, availability, qualifications and/or exam sites information.



Formulario
F245-051-000
 
Independent Medical Exam Comments
Used by the injured worker to provide comments to L&I about their recent medical exam by an IME.

Formulario
F245-053-000

Otro(s) idioma(s):
Español
 
Comentarios Sobre el Exámen Médico Independente

Usado por el trabajador lesionado para proporcionarle comentarios a L&I sobre su examen médico reciente de un Examen Médico Independiente (IME, por su sigla en inglés).



Formulario
F245-053-999

Otro(s) idioma(s):
Inglés
 
Submission of Provider Credentials for Interpretive Services

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.



Formulario
F245-055-000
 
Interpretive Services Appointment Record (ISAR)

This form is used by interpreters to verify to L&I (state fund and Crime Victims claims) and self-insured employers for interpretive service at medical or vocational visits.

When ordering, there is a limit of 4 pads, or 100 copies total.



Formulario
F245-056-000
 
Frequently Asked Questions about Job Modifications
Fact sheet: Answers questions employers, workers and doctors may have about job modifications, including when to request a job-modification consultant and who pays for the costs involved.

Publicación
F245-057-000
 
Independent Medical Exam Template

Template used by a doctor during an independent medical exam.



Formulario
F245-058-000
 
Physical Therapy / Occupational Therapy Progress Report to Claim Managers

The physical / occupational therapist uses this report to identify the clinical goals and return to work objectives of the injured worker.



Formulario
F245-059-000
 
Statement for Miscellaneous Services

This bill form is used by providers and injured workers to bill the department for services such as dental care; glasses; medical equipment; nursing home services; interpreter services; services workers pay for out of pocket; and other services. Information on how to bill the department can be found in the General Provider Billing Manual [F248-100-000].

 



Formulario
F245-072-000

Otro(s) idioma(s):
Español
 
Declaración para servicios misceláneos

Formulario:  Es utilizado por proveedores y trabajadores lesionados para cobrarle al Departamento por servicios tales como, cuidado dental; lentes; cuidado de enfermería en el hogar; equipo médico, servicios de intérprete; servicios que los trabajadores pagan por su cuenta y otros servicios.



Formulario
F245-072-999

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

Bill form for prescription charges. May be used by a pharmacy to submit drug charges, or by a worker to request reimbursement for prescriptions paid out of pocket. See the General Provider Billing Manual (F248-100-000) for information on completing this form.



Formulario
F245-100-000
 
CMS 1500 (formerly L&I Health Insurance Claim form)

Used by providers to be reimbursed for services. It is NOT for use by injured workers to submit a claim to L&I.



Formulario
F245-127-000
 
Travel Reimbursement Request

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



Formulario
F245-145-000

Otro(s) idioma(s):
Español
 
Solicitud para el reembolso de gastos de viaje

Los trabajadores lesionados usan este formulario para solicitar reembolso de los gastos de viaje usados para recibir tratamiento, capacitación y/o servicios vocacionales.



Formulario
F245-145-999

Otro(s) idioma(s):
Inglés
 
Provider's Request for Adjustment

Providers use this to report total overpayment, partial overpayment and/or underpayment by L&I.



Formulario
F245-183-000
 
Your Independent Medical Exam

Pamphlet/booklet: Answers the most common questions about independent medical exams and when and why an injured worker may be required to receive one. Includes the "IME Travel & Wage Reimbursement Request" form.



Formulario
F245-224-000

Otro(s) idioma(s):
Español
 
Su examen médico independiente

Folleto: Respuestas a las preguntas más comunes sobre los exámenes médicos independientes y cuándo y por qué podría requerirse que un trabajador lesionado asistiera a uno.  Incluye el formulario examen médico independiente (IME, por su sigla en inglés) - Solicitud para el reembolso de gastos de viaje y salario. Este formulario es solamente para el uso de negocios autoasegurados y sus trabajadores.



Formulario
F245-224-999

Otro(s) idioma(s):
Inglés
 
Labor and Industries Prosthetic Device Request Form

Labor and Industries Prosthetic Device Request



Formulario
F245-340-000
 
Job Modification Assistance Application

For use by an vocational counselor, employer, etc. to request modification for the injured workers job. This may involve tools and equipment that is purchased through L&I.



Formulario
F245-346-000

Otro(s) idioma(s):
Español
 
Modificacion en el trabajo solicitud de asistencia

Para ser utilizado por un consejero vocacional, empleador, etc. para solicitar modificación de empleo para el trabajador lesionado.  Esto puede incluir herramientas y equipo comprado por L&I.  



Formulario
F245-346-999

Otro(s) idioma(s):
Inglés
 
Pre-Job Accommodation Assistance Application

For use by a therapist or vocational provider to request job modification for an injured worker before the injured workers is employed, possibly in a retraining program. This may involve tools and equipment that is purchased through L&I.



Formulario
F245-350-000

Otro(s) idioma(s):
Español
 
Adaptación previa al trabajo solicitudad de ayuda

Formulario:  Este formulario puede utilizarlo un terapeuta o proveedor vocacional para solicitar una modificación de empleo para un trabajador lesionado antes de que el trabajador lesionado sea empleado, posiblemente en un programa de capacitación.  Esto puede incluir herramientas y equipo comprado por L&I.





Formulario
F245-350-999

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

Injured worker agrees to the ownership terms of the tools and/or equipment purchased as part of their training plan by L&I.



Formulario
F245-351-000

Otro(s) idioma(s):
Español
 
Acuerdo de propiedad de herramientas y equipo para el plan de formacion profesional

Formulario: El trabajador lesionado está de acuerdo con los términos de propiedad de las herramientas y/o el equipo comprado como parte de su plan de capacitación de L&I.



Formulario
F245-351-999

Otro(s) idioma(s):
Inglés
 
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.



Formulario
F245-365-000
 
UB04 HCFA 1450

Used by hospitals to bill L&I for inpatient/outpatient services. This version includes NPI number.



Formulario
F245-367-000
 
Housing and Board Cost Encumbrance
To record the costs for housing and board. For use only with plans approved after 1/1/2008.

Formulario
F245-372-000
 
Training Plan Cost Encumbrance

To record the training costs. For use only with plans approved after 1/1/2008.



Formulario
F245-374-000
 
Transportation Cost Encumbrance

To record the costs for transportation. For use only with plans approved after 1/1/2008.



Formulario
F245-375-000
 
Plan Time Encumbrance
To record the work plan time. For use only with plans approved after 1/1/2008.

Formulario
F245-376-000
 
Long Term Care Assessment Tool

You must mail or fax form. No emailed forms are accepted. This assessment tool is provided by L&I assessment to determine the medically appropriate level of care that will meet the Injured Worker’s needs, abilities and safety in a residential facility. This assessment is not intended as a substitute for DSHS annual assessment & treatment plan, which is the sole financial responsibility of the facility.



Formulario
F245-377-000
 
Notice of Independent Medical Exam No-Show or Late Cancellation

Notice of Independent Medical Exam No-Show or Late Cancellation



Formulario
F245-382-000
 
Independent Medical Examination Fax Cover Sheet

Independent Medical Examination Fax Cover Sheet



Formulario
F245-383-000
 
Hearing Aid Repair Authorization Fax Request

Hearing Aid Repair Authorization Requests. If you need to purchase or replace a hearing aid, fax all of the information required by Medical Aid Rules and Fee Schedule (MARFS) including the Hearing Services Worker Information (F245-049-000) to 360-902-6252.



Formulario
F245-384-000
 
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.)
Filled out by the provider when they treat an injured worker. See web links below for: Latest payment amounts, Updates and corrections, and Review payment policy. For use in place of Minimum Data Set (MDS) 3.0 beginning October 1, 2010.

Formulario
F245-392-000
 
L&I Chiropractic Consultant Application

This application is for doctors applying for second opinion examiner (consultant) status. Current consultants do not need to reapply.



Formulario
F245-393-000
 
HCFA Proprietary Format Companion Guide
This guide details the HCFA proprietary format structure and provides information regarding electronic billing to the department via Provider Express Billing (PEB).

Formulario
F245-394-000
 
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.

Formulario
F245-397-000
 
ASC X12N 005010 EDI Transactions Companion Guide
Description: This guide details the HIPAA ASC X12N 005010 format structure for EDI and provides information regarding electronic billing To the department via Provider Express Billing (PEB)

Manual
F245-398-000
 
Pharmacy Companion Guide

This guide details the HIPAA ASC X12N 004010 format structure for 835 Pharmacy Remittance Advice and provides information regarding electronic billing to the department via Provider Express billing (PEB)



Manual
F245-400-000
 
Washington Practitioner Application

Washington Practitioner Application is used by providers applying for the L&I Provider Network.



Formulario
F245-411-000
 
Interpreter Services for Injured Workers and Crime Victims

Flier: Describes interpreter services available to injured workers and crime victims. Covers how to get an interpreter; who can interpret and get paid for it; and basics of interpreter's professional conduct.



Publicación
F245-412-000

Otro(s) idioma(s):
Español
 
Servicios de intérprete para trabajadores lesionados y víctimas de crimen

Volante: Describe los servicios de intérprete disponible a los trabajadores lesionados y a las víctimas de crimen.  Incluye información de cómo obtener un intérprete; quién puede interpretar y recibir pago; y el concepto básico de conducta profesional del intérprete.



Publicación
F245-412-999

Otro(s) idioma(s):
Inglés
 
Quick Reference Card for Providers

Flyer or small poster for administrative staff for health-care and vocational providers: lists the most frequently used procedure codes and fees. The back highlights the most popular or frequently used web pages for providers and their staff. Provides tips for speeding up authorizations and for billing self-insured employers.



Publicación
F245-414-000
 
Department of Labor and Industries Home Modification Acknowledgement of Responsibilities

Used by both workers and bidding contractors to read, sign and submit to L&I to verify that they have read, understand and accept their respective responsibilities in the home modification process.



Formulario
F247-003-000

Otro(s) idioma(s):
Español
 
Modificacion en la vivienda Reconocimiento de responsabilidades

Utilizada tanto como por los trabajadores y contratistas de licitación para leer, firmar y someter a L&I para verificar que han leído, entendido y aceptado sus responsabilidades respectivas en el proceso de modificación de viviendas



Formulario
F247-003-999

Otro(s) idioma(s):
Inglés
 
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



Formulario
F248-011-000
 
Electronic Billing Authorization

To authorize L&I to accept electronically submitted bills for services provided to injured workers (2 pages).



Formulario
F248-031-000
 
Hotline Tips for Medical Services Providers
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.

Publicación
F248-040-000
 
Occupational or Physical Therapy Treatment Authorization Fax Request

Used by a therapy provider/clinic to request authorization for outpatient occupational or physical therapy services for L&I claims.



Formulario
F248-055-000
 
General Provider Billing Manual

General billing information for those providers that bill the department.



Manual
F248-100-000
 
Statement for Home Nursing Services

Used to bill L&I for reimbursement of home nursing services.



Formulario
F248-160-000
 
Payroll Service Provider - Quarterly Reporting Bulk Filing Enrollment Form

Used by payroll services to enroll and register with L&I for downloading/uploading account information from the Express Filing site using an electronic list (text file) of accounts.



Formulario
F248-343-000
 
Power of Attorney for Electronic Remittance Advice

Providers complete this form to authorize a clearinghouse or third party to receive the EDI 835 Electronic Remittance Advice file from L&I's Provider Express Billing (PEB).



Formulario
F248-355-000
 
Massage Therapy Treatment Authorization Fax Request

Used by a licensed massage practitioner/clinic to request authorization for outpatient massage therapy services for L&I claims.



Formulario
F248-357-000
 
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.



Formulario
F248-361-000

Otro(s) idioma(s):
Español
 
Solicitud de cuenta para proveedores fuera del país

Esta solicitud es para proveedores de salud fuera de los Estados Unidos.  Los proveedores que brindan tratamiento a los trabajadores lesionados deben tener un número de proveedor para poder cobrarle al Departamento.



Formulario
F248-361-999

Otro(s) idioma(s):
Inglés
 
Medical Payment Guidance

Flyer: Describes how a payment for health-care services is mailed separately from the explanation for the payment (the remittance advice). An illustration explains how to link a payment with its explanation. Also includes information about how providers can always find their remittance advices online through L&I's Provider Express Billing.



Publicación
F248-366-000
 
Third Party Recovery Worksheet

Used by third party attorneys to calculate distribution of proposed settlements in third party claims.



Formulario
F249-006-111
 
Injured by a third party?  

Brochure: Summarizes the legal rights and options an injured worker has if a third-party action pertains to his/her workers' compensation claim. Includes the Third Party Election Form that must be completed by the worker. Note: The form must be printed, signed and mailed.



Formulario
F249-008-000

Otro(s) idioma(s):
Español
 
¿Lesionado por un tercero? Usted tiene opciones legales

Folleto: Un resumen de los derechos legales y opciones que tiene un trabajador lesionado si una acción contra un tercero está relacionada con su reclamo de compensación para los trabajadores. Incluye el Formulario de elección contra terceros que debe ser completado por el trabajador. Aviso:  El formulario debe imprimirse, firmarse y enviarse por correo.

 



Formulario
F249-008-999

Otro(s) idioma(s):
Inglés
 
Workers' Compensation Insurance Manual

This manual covers Chapter 296-17 and 296-17A WAC. Topics covered are employer reporting requirements for workers' compensation; employer classification for workers' compensation; and rates and experience rating rules for workers' compensation.



Manual
F213-178-000
 





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