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Results for: Claims and Insurance - For Medical Providers
Title Number / Language
3 Things to Know about L&I's Medical Provider Network  F242-406-000 (English)
 F242-406-999 (Spanish)
Activity Coaching Flyer for Providers  F280-062-000 (English)
Activity Diary  F245-444-000 (English)
Activity Prescription Form (APF)  F242-385-000 (English)
Add Group Packet - Network Provider Account and Credentialing  F245-449-000 (English)
Adult Tuberculosis Screening Tool for Workers Exposed to Respirable Crystalline Silica  F252-113-000 (English)
Attending Provider's Return-to-Work Desk Reference  F200-002-000 (English)
Authorization to Release Information  F262-005-000 (English)
 F262-005-214 (Cambodian)
 F262-005-255 (Korean)
 F262-005-294 (Russian)
 F262-005-319 (Vietnamese)
 F262-005-200 (Albanian)
 F262-005-201 (Amharic)
 F262-005-203 (Arabic)
 F262-005-206 (Azeri/Azerbaijani)
 F262-005-211 (Bosnian)
 F262-005-212 (Bulgarian)
 F262-005-213 (Burmese)
 F262-005-220 (Chinese Simplified)
 F262-005-221 (Chinese Traditional)
 F262-005-226 (Dari)
 F262-005-233 (Farsi/Persian)
 F262-005-232 (French)
 F262-005-236 (German)
 F262-005-243 (Hmong)
 F262-005-244 (Hungarian)
 F262-005-250 (Karen)
 F262-005-257 (Kurdish)
 F262-005-261 (Laotian)
 F262-005-272 (Marshallese)
 F262-005-274 (Mien)
 F262-005-280 (Nepali/Nepalese)
 F262-005-283 (Oromo/Afaan Oromo)
 F262-005-289 (Polish)
 F262-005-290 (Portuguese)
 F262-005-291 (Punjabi/Panjabi)
 F262-005-293 (Romanian)
 F262-005-297 (Samoan)
 F262-005-303 (Somali)
 F262-005-307 (Tagalog/Filipino)
 f262-005-309 (Telugu/Telegu)
 f262-005-309 (Telugu/Telegu)
 F262-005-310 (Thai)
 F262-005-311 (Tibetan)
 F262-005-312 (Tigrinya/Tigrigna)
 F262-005-315 (Turkish)
 F262-005-316 (Ukrainian)
 F262-005-317 (Urdu)
 F262-005-334 (Kunama)
Billing Guidelines for Sexual Assault Examinations: Crime Victims Compensation Program  F800-100-000 (English)
Botulinum Toxins for Non-Migraine Indications  F252-122-000 (English)
Chiropractic Consultant Application  F245-393-000 (English)
Chronic Opioid Request Form  F252-091-000 (English)
Communicating with workers who do not speak English well  F245-455-000 (English)
Crime Victim Compensation Program Sexual Assault Exam Report  F800-098-000 (English)
Crime Victims Compensation Program Progress Note: Form III  F800-082-000 (English)
Crime Victims Compensation Program Termination Report: Form VI  F800-085-000 (English)
Crime Victims Compensation Program Treatment Report: Form IV  F800-083-000 (English)
Crime Victims Compensation Program Treatment Report: Form V  F800-084-000 (English)
Crime Victims Statement for Home Nursing Services  F800-070-000 (English)
Department of Labor and Industries Home Modification Acknowledgement of Responsibilities  F247-003-000 (English)
Direct-Acting Antiviral for Hepatitis C Prior Authorization Form  F252-112-000 (English)
Electronic Billing Authorization  F248-031-000 (English)
Exception to Three-Day Limit of Opioids for Dental Procedures Prior Authorization Request  F252-118-000 (English)
Frequently Asked Questions about Job Modifications  F245-057-000 (English)
Functional Recovery Interventions (RFI) Tracking Sheet  F245-420-000 (English)
Hearing Impairment Calculation Worksheet  F252-007-000 (English)
Helpful Tips for Medical Services Providers  F248-040-000 (English)
Helping Providers Understand the Crime Victims Compensation Program  F800-102-000 (English)
Home Modification for Workers with Catastrophic Injuries  F252-060-000 (English)
 F252-060-999 (Spanish)
Home Modification for Workers with Catastrophic Injuries - Questions and Answers for Contractors  F252-061-000 (English)
 F252-061-999 (Spanish)
How to Bill for an Occupational Disease History Report (Code 1055M)  F242-432-000 (English)
Independent Medical Exam Doctor's Estimate of Physical Capacities  F242-387-000 (English)
Independent Medical Examination (IME) Provider Exam Sites  F245-047-000 (English)
Individual Vocational Provider Account Change Form  F252-021-000 (English)
Interpreter Services for Injured Workers and Crime Victims  F245-412-000 (English)
 F245-412-214 (Cambodian)
 F245-412-255 (Korean)
 F245-412-294 (Russian)
 F245-412-319 (Vietnamese)
 F245-412-220 (Chinese Simplified)
 F245-412-221 (Chinese Traditional)
 F245-412-303 (Somali)
L&I Medical Provider Network Credentialing Checklist  F245-445-000 (English)
Labor and Industries Prosthetic Device Request Form  F245-340-000 (English)
Medical Device Review Request  F252-013-000 (English)
Medical Examiners' Handbook  F252-001-000 (English)
Medical Payment Guidance  F248-366-000 (English)
Mental Health Services Fee Schedule  F245-422-000 (English)
Negative Pressure Wound Therapy  F252-114-000 (English)
Notice of Occupational Disease or Infection  F242-243-000 (English)
Nurse Case Management Initial Care Management Plan  F245-442-000 (English)
Nurse Case Management Progress Report  F245-439-000 (English)
Nurse Case Management Qualis Progress Report  F245-441-000 (English)
Occupational Disease Claims in Workers' Compensation  F252-117-000 (English)
OnabotulinumtoxinA for Prevention of Chronic Migraine  F252-123-000 (English)
Opioid Treatment Agreement  F252-095-000 (English)
 F252-095-999 (Spanish)
Performance Based Physical Capacities Evaluation  F245-023-000 (English)
Power of Attorney for Electronic Remittance Advice  F248-355-000 (English)
Pre-Job Accommodation Assistance Application  F245-350-000 (English)
Preauthorization Request for Services for State Fund Workers' Compensation Patients  F242-397-000 (English)
Provider Account Application  F248-011-000 (English)
Provider Account Application - Independent Medical Examiner (IME)  F245-046-000 (English)
Provider Account Change Form  F245-365-000 (English)
Provider Change Form for Crime Victims Compensation  F800-089-000 (English)
Provider's Initial Report (PIR)  F207-028-000 (English)
Quick Reference Card for Providers 2016  F245-414-000_2016 (English)
Quick Reference Card for Providers 2017  F245-414-000_2017 (English)
Quick Reference Card for Providers 2018  F245-414-000_2018 (English)
Quick Reference Card for Providers 2019  F245-414-000_2019 (English)
Referral for Activity Coaching Program  F245-413-000 (English)
REFUND NOTIFICATION Refunding Money to L&I to correct your account?  F245-043-000 (English)
Report of Accident (ROA) Workplace Injury, Accident or Occupational Disease  F242-130-000 (English)
Report of Accident - Injured Worker Instructions  F242-134-999 (Spanish)
Report of Accident – Injured Worker Instructions  F242-134-214 (Cambodian)
 F242-134-255 (Korean)
 F242-134-294 (Russian)
 F242-134-319 (Vietnamese)
 F242-134-201 (Amharic)
 F242-134-203 (Arabic)
 F242-134-211 (Bosnian)
 F242-134-220 (Chinese Simplified)
 F242-134-221 (Chinese Traditional)
 F242-134-233 (Farsi/Persian)
 F242-134-291 (Punjabi/Panjabi)
 F242-134-303 (Somali)
 F242-134-307 (Tagalog/Filipino)
Residential Care Assessment Tool  F245-377-000 (English)
Sample Format for Vocational Testing Report  F252-051-000 (English)
Sample Self-Employment Agreement  F252-032-000 (English)
Statement for Compound Prescription  F245-010-000 (English)
Statement for Home Nursing Services  F248-160-000 (English)
Statement for Retraining and Job Modification Services  F245-030-000 (English)
Statewide Payee Registration  F248-036-000 (English)
Stay at Work Exam Room Card  F243-009-000 (English)
Subacute Opioid Request Form  F252-097-000 (English)
Supplemental Provider Application for the Orthopedic & Neurological Surgeon Quality Project  F245-379-000 (English)
UB04 HCFA 1450  F245-367-000 (English)
Vocational Training Plan Ownership Agreement for Tools and Equipment  F245-351-000 (English)
Workers: Activity coaching can help you get back to doing what you love  F280-061-000 (English)
 F280-061-999 (Spanish)
 F280-061-200 (Albanian)
Your Independent Medical Exam (IME): Crime Victims Compensation Program  F800-115-000 (English)
Your Independent Medical Exam: For Employees of Self-Insured Businesses  F207-202-000 (English)
 F207-202-214 (Cambodian)
 F207-202-255 (Korean)
 F207-202-294 (Russian)
 F207-202-999 (Spanish)
 F207-202-319 (Vietnamese)
 F207-202-220 (Chinese Simplified)
 F207-202-221 (Chinese Traditional)
 F207-202-303 (Somali)

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