Provider Account Application {F248-011-000}

STATE OF WASHINGTON DEPARTMENT OF LABOR AND INDUSTRIES INSURANCE SERVICES HEALTH SERVICES ANALYSIS PO Box 44261 Olympia Washington 98504-4261 Dear Provider, Thank you for your interest in treating or providing services for Washington222s injured workers and crime victims. This application is for providers who are: In-state, non-primary care physicians, such as Physical, Occupational and Massage Therapists, etc. Facilities such as DME Supplier, Hospital, Pharmacy, Laboratory, Nursing Home, etc. Vendors such as Transportation, Vocational Rehabilitation, Training, etc. Out-of-state providers treating Washington state injured workers and crime victims. To apply for a provider account, submit: A completed Provider Account Application. If you are a member of a group, each provider must submit a separate application to bill for services. A signed copy of the Provider Agreement page (page 7). A completed Statewide Payee Registration form (two pages). Note: Please complete Steps 1 through 5. Submit a copy with each provider222s application. L&I cannot accept any forms with crossed or whitened out information. The legal name in Step 2 and 5 must match the legal name associated with the Tax ID. The address on Step 2 of the Statewide Payee Registration must match the payment address on the Provider Account Application. L&I cannot accept a federal W-9 in substitute for the Statewide Payee Registration form. A copy of your license or certification as required by your state health regulations. Once your application is processed, you will receive a letter containing your L&I provider account number. This is the number that you will use to bill the department. L&I offers electronic billing. For more information, visit: www.Lni.wa.gov/ElectronicBilling. If you have any questions, please email: PACMail@Lni.wa.gov. Thank you, Provider Accounts and Credentialing Unit American LegalNet, Inc. www.FormsWorkFlow.com F248-011-000 Provider Account Application 11-2017 Page 2 of 8 Application Instructions Complete this application by printing clearly. Use dark ink. Individual providers must complete Sections A, B, and D. Facilities must complete Sections A, C, and D. A. Business Information 1. Credentialing Contact Information: This is the person L&I can contact if there are credentialing questions or if additional documentation is needed for this application (i.e. credentialer, office manager, etc.). 2. Business Information: Number (SSN) used when billing L&I. Provide only one. where services are provided. This is a Type 2 NPI number. group number. 3. Physical Location Address: does not accept a P.O. Box as a physical address of the business. 4. Payment Address: o Explanation of Benefits (EOBs) and Remittance Advices (RAs). o Payments will be sent to this address if a check in the US mail is selected. If there is an issue with the direct deposit, payments will be sent to this address instead. o This address must match the payment address on Step 2 of the Statewide Payee Registration form. Phone Num 5. Correspondence Address: Corrnumber L&I can call to contact the provider/office staff. provider/office staff. American LegalNet, Inc. www.FormsWorkFlow.com F248-011-000 Provider Account Application 11-2017 Page 3 of 8 B. Individual License & Certification Information (If you222re applying for a facility only, you may skip this section.) 1. indicated on his/her license or certification. A separate application is required for each provider who renders services. first, middle initial. Gender. and state where issued for provider222s professional license, DEA, and/or certification. Attach a copy of provider222s current license/DEA/certification to the application. enter provider222s individual NPI number that will be used for billing purposes. This is a Type 1 NPI number. Sponsoring supervising physician222s name. Active L&I Provider Number for the sponsoring or supervising physician providers must have an active account under the same tax identification number (TIN). 2. Find-A-the provider will be listed on the website. C. Facility License & Certification Information (If you222re applying for an individual provider, you may skip this section.) 1. rk only one box next to the type of facility or business. Facility License/DEA/Cewhere issued, and the status of the facility license, DEA, accreditation, certification and/or business license. Attach a copy of the current license/DEA/accreditation/ certification/business license to the application. purposes. This a Type 2 NPI number. enter NCPDP/NABP Number. attach a copy of CLIA. L&I can222t accept a waived CLIA. D. Provider Agreement Please review and sign. If the Provider Agreement has been altered or is missing a signature, the application will be considered incomplete and returned unprocessed. American LegalNet, Inc. www.FormsWorkFlow.com F248-011-000 Provider Account Application 11-2017 Page 4 of 8 E. Statewide Payee Registration Form Please complete Steps 1 through 5. Submit a copy for each provider222s application. L&I can222t accept any forms with crossed or whitened out information. The legal name in Step 2 and Step 5 must match the legal name associated with the Tax ID. The address on Step 2 of the Statewide Payee Registration must match the payment address on the Provider Account Application. L&I can222t accept a federal W-9 in substitute for the Statewide Payee Registration form. Note: Refer to the separate instructions for completing the Statewide Payee Registration form. American LegalNet, Inc. www.FormsWorkFlow.com Name of Applicant (Last, First, MI) or Facility F248-011-000 Provider Account Application 11-2017 Page 5 of 8 Mail or fax completed applications to: Provider Accounts and Credentialing PO Box 44261 Olympia WA 98504-4261 Fax: 360-902-4484 Provider Account Application Please print clearly and use dark ink. Questions? Email: PacMail@Lni.wa.gov For L&I Use Only Provider Account Number A. Business Information 1. Contact Information who L&I can contact with questions about this application Name Email Address Phone Number Fax Number 2. Business Information only one) Practice Name (DBA) Organization NPI L&I Group Number 3. Physical Location Address where services are provided Street Address City State Zip Code Phone Number Fax Number 4. Payment Address where you want your checks and remittance advices to go Same as Location Address Address City State Zip Code Phone Number Fax Number 5. Correspondence Address where you want general L&I mail to go Same as Location Address Same as Payment Address Address City State Zip Code Phone Number Fax Number American LegalNet, Inc. www.FormsWorkFlow.com Name of Applicant (Last, First, MI) or Facility F248-011-000 Provider Account Application 08-2015 Page 6 of 8 B. Individual License and Certification Information A separate application is needed for each provider. All providers must include a current copy of the provider222s state license. Number. of your certification. Provider Credential for Interpretative Services Form (F245-055-000) and a copy of your certification. 1. Audiologist Occupational Therapist Chiropractor Optician COHE Administrator Optometrist Dentist Osteopathic Physician Dietitian Physical Therapist East Asian Acupuncture Physician Health Service Coordinator Physician Assistant (Certified) Hearing Aid Fitter/Dispenser Podiatrist Interpreter Prosthetic/Orthotics Massage Therapist Psychologist Naturopath Respiratory Therapist Nurse Speech/Language Pathologist Provider Name (Last, First, Middle Initial) Gender License Number License Issued Date License Expiration Date State Where Issued DEA Number DEA Issued Date DEA Expiration Date State Where Issued Certification Certification Issued Date Certification Expiration Date Certification Status Individual NPI Language(s) Fluently Spoken by Provider Provider Specialty NCCPA Number (PACs Only) Sponsoring/Supervising Physician222s Name (PACs Only) L&I # for Sponsoring/Supervising Physician (PACs Only) 2. Find-A-Doc (FAD) Websites Do you want your contact information included on the Find-A-Doc websites so workers or crime victims may locate your business for services in their area? If left blank, the provider will be