Washington > Workers Comp > Claims
Provider Credentialing Change Form F245-365-000 - Washington
| Provider Credentialing Change Form Form. This is a Washington form and can be used in Claims Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Mail to: L&I Provider Credentialing PO Box 44261 Olympia, WA 98504-4261 Phone 360-902-5140 Fax 360-902-4484 Provider Credentialing Change Form Use this form to notify L&I of any change to your provider account information. Sections 1 & 7 must be completed. To update your tax name and address, send a signed W-9 with this form. A W-9 alone will not update your billing address. Mail or fax to contact information listed above. 1. Basic account information Provider Credentialing Name Federal Tax ID L&I Provider # for individual L&I Provider # for group 2. Select only one method you want to receive your RAs I want to receive electronic remittance advices via Provider Express Billing (PEB). Visit PEB at: www.lni.wa.gov/ClaimsIns/Providers/Billing/BillLNI/Electronic I want to receive paper remittance advices. 3. Change the name on my account (If you are changing the name of an individual, you must attach documentation: Practice license, marriage license, divorce decree, or court order. You do not need documentation to change your business name.) Previous Provider Name New Provider Name 4. Change the address of my office's physical address (This address cannot be a PO Box.) Old Physical Address Address City Phone State ZIP New Physical Address Address City Phone State ZIP 5. Change my billing address Check if you want us to send all mail here. (This address can be a PO Box.) Old Billing Address Address City Phone State ZIP New Billing Address Address City Phone State ZIP 6. Inactivate my L&I account Provider Number Reason Provider Name Effective Date 7. I authorize this change by signing below Date Signature Phone F245-365-000 Provider Credentialing Change Form 12-11 RESET American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
