IME Provider Account Application {F245-046-000}

DEPARTMENT OF LABOR AND INDUSTRIES PO Box 44322 Olympia Washington 98504-4322 STATE OF WASHINGTON Dear Provider, Thank you for your interest in providing services to our workers. Attached you will find the Independent Medical Exam (IME) Provider Account Application. To receive payment, you must be approved as an IME Provider and be assigned an IME provider account number. Practitioners, please submit the following documents: Application (2 pages) Signed and dated attestation Provider agreement (2 pages) IME Provider Exam Sites Statewide Payee and W-9 Certificate of successful completion of the Medical Examiners' Handbook test Current copy of the provider's professional license Current copy of the provider's curriculum vitae Copy of fellowship certificate(s) if applicable Documentation of required Continuing Medical Education (CME) hours if applicable Firms, please submit the following documents: Application (2 pages) Certificate of successful completion of the Medical Examiners' Handbook test for Quality Assurance staff Copy of business license for each exam site location IME Provider Exam Site form Signed and dated Provider Agreement Statewide Payee and W-9 If this is your initial application and you are approved, you will receive: · Your new provider account number. · An L&I Toolkit CD which contains: o Medical Aid Rules and Fee Schedules. o General Billing Manual and forms. o Links to publications such as the Medical Examiners' Handbook. If this is your reapplication and you are approved, you will receive notification of your approval. Additional information about becoming an IME can be found on our website at www.IMEs.Lni.wa.gov. For more information about: · State Fund Workers Compensation IME billing and payment questions; contact Provider Hotline at 800-848-0811. · State Fund and Self Insured Medical Aid Rules and Fee Schedule at: www.Lni.wa.gov/ClaimsIns/Providers/Billing/default.asp · Crime Victims IME billing and payment questions; contact Crime Victims at 800-762-3716. · Crime Victims Compensation Fee Schedule at: www.Lni.wa.gov/ClaimsIns/Crimevictims/ProvResources/ · IME Tracking System (IMETS): a list of all approved IME examiners and firms is located online at the IME webpage www.IMES.Lni.wa.gov. Select "Find a Medical Examiner." For questions about IMETS, call 360-902-6815. Sincerely, Gary Walker, MA, MPA Provider Credentialing and Compliance F245-046-000 IME Provider Account Application and Notice 02-2013 American LegalNet, Inc. www.FormsWorkFlow.com Mail completed applications to: Department of Labor and Industries Provider Credentialing and Compliance PO Box 44322 Olympia WA 98504-4322 IME Provider Account Application A. Application Information I am applying as a(n): Individual Examiner Examiner working with a firm Firm This application is for: I am working: In Washington State Outside of Washington State New provider/New application Current provider ­ requesting additional provider number Current provider ­ renewal B. Tax Reporting Information 1. Tax payer identification number (EIN or SSN ­ must match the W-9 submitted with this application) C. Payee Account and Billing Information 2. Business name (name used on your bills) 4. Physical location of business Physical address line 2 Physical city, state, and zip code 6. Location phone number 9. Medical Director name (Firms only) 3. Name and phone number of contact person 5. Billing address (where you want your check sent) Billing address line 2 Billing city, state, and zip code 7. Billing phone number 10. Medical Director professional license number D. Practitioner Information 11. Provider's name (Last, First, MI) 14. Type of license MD DO DC DDS/DMD 16. Practice specialty/subspecialty 18. Provider's mailing address Address line 2 City, state, and zip code 19. Provider's phone number DPM 12. Gender Male or Female 13. Date of birth (mm/dd/yyyy) 15. Professional license number 17. DEA number and expiration date 20. Provider's email address E. NPI Information 23. Organization name 21. Individual provider's name 22. Individual NPI number 24. Organization's NPI number F245-046-000 IME Provider Account Application and Notice 02-2013 American LegalNet, Inc. www.FormsWorkFlow.com F. Medical Qualifications 1. All applicants must complete the attached Attestation Questionnaire. Applicant Name: 2. Attach certification of a passing test score on the Medical Examiners' Handbook test. 3. Doctors licensed to perform medicine and surgery (MD), osteopathic medicine and surgery (DO), podiatric I am certified by a board recognized by: American Board of Medical Specialties, name of board(s): American Osteopathic Assn. Bureau of Osteopathic Specialties, name of board(s): American Podiatric Medical Association, name of board(s): I am not board certified Have you completed a residency? Are you in the process of completing your Board certification? curriculum vitae and chiropractic license. medicine and surgery (DPM) must complete the following. Attach a copy of your current dated curriculum vitae, board certification, certification of your specialty, and any verification of fellowship attendance. No No Yes (Attach documentation) Yes - Anticipated completion date:____________ 4. Doctors licensed to practice chiropractic must complete the following. Attach a copy of your current dated I served as an L&I chiropractic consultant for at least 2 years. Dates: I attended the department's Chiropractic IME Examiner seminar. New applicants must have attended in the previous 2 years. Date attended: 5. Dental examiner applicants must complete the following. Attach a copy of your current dated curriculum vitae and dental license. I have a minimum of two years of post-doctoral clinical experience. Dates:_____________________________ G. Practice and Continuing Education Information 1. Do you currently provide patient related services (excluding IMEs)? Per week: Per month: Per year: If yes, indicate how many hours (select one reporting method below): Yes No If no, list the date you retired from direct patient care:_ _______________________________________________ 2. Name of practice, affiliation, or clinic: ____________________________________________________________ 3. Effective date at primary practice location:_________________________________________________________ 4. Contact Name: _______________________________________________________________________________ 5. Practice website: ______________________________________________________________