Washington > Workers Comp > Claims
Provider Account Application F248-011-000 - Washington
| Provider Account Application Form. This is a Washington form and can be used in Claims Workers Comp . |
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Dear Provider: STATE OF WASHINGTON DEPARTMENT OF LABOR AND INDUSTRIES Tumwater Building, PO Box 44261 Olympia, Washington 98504-4261 Thank you for your interest in providing services to our workers and crime victims. Attached you will find the Provider Application necessary for obtaining an account number with us. To receive payment, an active provider account number is necessary. What do I need to submit? * · Completed application. · Signed Provider Agreement. · License or Certification required by your state's Department of Health regulations. · W-9 Form. * A separate application is necessary for each, individual provider. What happens next? Once your application is accepted, you will receive a welcome packet and CD containing: · Your new provider account number. · An L&I Toolkit CD which contains: o Medical Aid Rules and Fee Schedules. o Billing manuals and forms. o Address Change Form--please report changes to your account within 15 days of change. o Quick Reference Guide and Provider Tip Sheet. o Attending Doctor's Handbook. Want to speed up bill payment? * Electronic billing will speed bill processing time. For information call the Electronic Billing Unit at (360)902-6511, or visit our Website http://www.lni.wa.gov/ClaimsIns/Providers/Billing/BillLNI/Electronic. *Electronic Billing is not yet available for providers billing Crime Victims Compensation. How can my practice be publicized? The Find-A-Doc (FAD) search engines are Internet applications that allow workers, their representatives, or crime victims to search for Labor and Industries providers--filtered by providers' primary location, type, and specialty--within users' specified number of miles from their location. We publish all active accounts to these websites unless you indicate on the application that you do not wish to be included in FAD. Need more information? Contact: · Provider Accounts: 360-902-5140--for questions concerning your account. · Provider Hotline: 1-800-848-0811--for State Fund Workers Compensation claims billing and payment questions. · Crime Victims: 1-800-762-3716--for Crime Victims Claims billing and payment questions. · State Fund Medical Aid Rules and Fee Schedule: http://www.lni.wa.gov/ClaimsIns/Providers/Billing. · Crime Victim Compensation Fee Schedule: http://www.lni.wa.gov/ClaimsIns/CrimeVictims/ProvResources. · FAD: 360-902-6613--for questions regarding the Find-A-Doc database. Sincerely, Sandra L. Chabot Provider Accounts Enclosures F248-011-000 Provider account application and notice 12-2010 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION INSTRUCTIONS Please use dark ink or type font of 12pt. or larger A. Tax Payer Information 1. Enter Tax Identification number or Social Security number. 2. Enter L&I Group number (only if you are part of a previously-established L&I group). B. Account and Billing Information 3. Enter the business name (name used on your bills). 4. Enter the name and number of the person we can call if we have questions about your application. 5. Enter the business physical location address. (This cannot be a PO Box). 6. Enter the billing address--where we mail your payments--as it appears on your bills submitted to the Department of Labor & Industries. 7. Enter the business location appointment phone number. (The number to call to make an appointment). 8. Enter the billing contact person's phone number. (The person who can answer questions regarding your bills). C. Individual Provider 9. Enter the name of the individual or organization providing services. 10. Enter the type of service(s) provided. Complete numbers 11-14 (if applicable to your provider type). 11. Enter the professional license number. 12. Enter the license issue date--month, day, and year. (Attach a copy of license). 13. Enter the date the license will expire (month, day, and year). 14. Enter the issuing state. 15. Enter your board certification # (only if you are Physical Medicine & Rehabilitation). 16. Enter the NCPDP or NABP number. (for pharmacy). 17. Enter the Drug Enforcement Agency (DEA) number--if applicable to provider type--and expiration date. Attach a copy of DEA permit 18. Enter supervising physician name and provider number--for Physician Assistants (PA-C) only. *A supervising physician is necessary to set up a PA-C account. D. National Provider Identifier (NPI) Information 19. Enter the individual name. 20. Enter the individual NPI number. 21. Enter the organization name. 22. Enter the organization NPI number. 23. Enter the subpart 10-digit number (if applicable). E. Agreement Page 24. Read and sign the agreement page F. Find-A-Doc (FAD) State Fund and Crime Victims Option 25. Select yes or no for being posted on the FAD Website and/or the Crime Victims Website. If left blank, you will be listed. G. Identify your Provider Specialty 26. Mark the box next to your provider type and/or specialty. 27. Provide any additional specialized information. (optional). NOTICE: The application is available at http://www.BecomeProvider.Lni.wa.gov or call (360) 902-5140 to have one sent to you. We accept signed photo copies of this application. F248-011-000 Provider account application and notice 12-2010 American LegalNet, Inc. www.FormsWorkFlow.com PROVIDER ACCOUNT APPLICATION Mail or FAX to: Department of Labor and Industries Attn: Provider Accounts PO Box 44261 Olympia WA 98504-4261 I nter net addr ess: http://www.lni.wa.gov/FormPub/Detail.asp?DocID=1652 Phone (360) 902-5140 FAX (360) 902-4484 A. Tax Payer Information 1. Tax payer identification number (EIN or SSN) ** Please Note: Use dark ink or type font of 12 pt. or larger. ***Please do not staple application 2. L&I provider group number ( if applicable) B. Account and Billing Information (all fields are required) 3. Business name (name used on your bills) 5. Business physical location address Business address line 2 Business city, state and zip code 7. Business location appointment phone number 4. Name and phone number of contact person 6. Billing address (where you would like your payments sent) Billing address line 2 Billing city, state and zip code 8. Billing phone number Please check if you would like all mail to go to the billing address. Unless otherwise notified, your claims-related correspondence will go to your physical address. C. Individual Provider or Organization Information - Please attach a copy of your medical license or certification 9. Provider's name (Last, First, MI) 10. Provider specialty / Services provided 1
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