Fill and Sign the Medical Forms Request Washington Claims Justia

PLACE STAMP HERE POST OFFICE WILL NOT DELIVER WITHOUT PROPER POSTAGE WAREHOUSE DEPARTMENT OF LABOR AND INDUSTRIES PO BOX 44843 OLYMPIA WA 98504-4843 tape here do not staple L&I MEDICAL FORMS REQUEST F208-063-000 1-05 City State ZIP+4 Mailing address Company name ATTN:Provider No: This is your return mailing label. Please type or print clearly. Quantity FormUnit of issue each F208-063-000 Medical Forms Request (this card) each F242-071-111 Occupational Disease Work Hist (cont) F242-071-000 Occupational Disease Work History each Quantity FormUnit of issue pad F245-346 Job Mod Asst App - Voc Rehab each F245-354-000 1st 52 Wk Trng Pln Cost Encumbrance F245-353-000 1st 52 Wk RTW Time Encumbrance each pad F242-079-000 Application to Reopen Claim pad F245-355-000 1st 52 Wk Bd & Rm Cost Encumbrance each F242-104-000 Worker's Guide/Ind Ins Benefits - Eng F245-356-000 2nd 52 Wk RTW Time Encumbrance pad each F242-104-999 Worker's Guide/Ind Ins Benefits - Span F245-357-000 2nd 52 Wk Trng Pln Cost Encumbrance pad F242-130-000 Accident Report each pad F245-358-000 2nd 52 Wk Bd & Rm Cost Encumbrance each F245-010-000 Statement for Compound Prescriptions each F248-011-000 Providers Application & Notice pad F245-030-000 Stmt for Retraining/Job Mod Services each F248-014-000 Hospital Services Billing Instructions each F245-037-000 Case Transfer Card each F248-015-000 Retraining & Job Mod Exp Billing Inst. each F245-072-000 Stmt for Miscellaneous Services - single sheet each F248-021-000 Pharmacy Prescriptions Billing Inst. each F245-072-111 Stmt for Miscellaneous Services - CFF each F248-036-000 Request for Taxpayer ID# - W-9 each F245-094-034 Med Aid Rules and Fee Schedules - CD each F248-088-000 Home Care Billing Instructions each F245-100-000 Stmt for Pharmacy Services - single sheet each F245-100-111 Stmt for Pharmacy Services - CFF each F248-094-000 HCFA 1500 Billing Instructions each F248-095-000 Miscellaneous Services Billing Instructions each F245-127-000 HCFA 1500 (L&I use only) - snap apart each F248-100-000 General Provider Billing Manual each F245-127-111 HCFA 1500 (L&I use only) - CFF each F248-160-000 Statement for Home Nursing Care each F245-145-000 Claimant Travel Expense Voucher - Eng each F252-001-000 Medical Examiner's Handbook each F245-145-999 Claimant Travel Expense Voucher - Span each F252-004-000 Attending Doctor's Handbook each F245-183-000 Provider's Request for Adjustment each F252-010-000 Medical Treatment Guidelines each F245-299-000 Consultation Referral Complete your request, fold in thirds, tape closed, affix postage and mail to the address at top of form. each F200-002-000 Attending Doctor's Return-to-Work Desk Reference each F200-001-000 Getting Back to Work: It's Your Job and Your Future (for patients)