Provider Account Change Form {F245-365-000}

F245-365-000 Provider Account Change Form 04-2019 Provider Account Change Form Provider Accounts & Credentialing PO Box 44261 Olympia WA 98504-4261 Fax: 360 - 902 - 4484 Questions? Email PacMail@Lni.wa.gov For L&I Use Only 226 Provider Account # 1. Account Information (Required) Provider /Business/Facility N ame Taxpayer Identification Number (EIN or SSN) Provider222s Account & Individual NPI Number Group Account & Organization NPI Number 2. Change the Name on My Account If you are changing the name of the individual, you must attach documentation: medical license, certification, marriage license, divorce decree, or court order. You do not need documentation to change your business name. Previous Provider/Business/Facility Name New Provider/Business/Fac ility Name 3. Add or Change the Existing NPI on My Account Old NPI (if applicable) New/Add NPI Reason for Change/Add: 4. Change the Address of My Office222s Location This is the address that will show in our Find-a-Doctor webpage Old Location New Location (This address cannot be a PO Box ) Address Address City State ZIP City State ZIP Phone Number Fax Number Phone Number Fax Number 5. Change My Payment Address To change this address an updated Statewide Payee Registration form must be submitted with this Change form. L&I does not accept the Federal W-9. Old Payment Address New Payment Address ( PO Box accepted ) Address Address City State ZIP City State ZIP Phone Number Fax Number Phone Number Fax Number 6. Change/Add My Correspondence Address Old Correspondence Address New Correspondence Address ( PO Box accepted ) Address Address City State ZIP City State ZIP Phone Number Fax Number Phone Number Fax Number 7. Inactivate My Provider Account Provider Account Number Provider/Business/Facility Name Effective Date Reason: 8. I authorize this change by signing below: (Required) L&I cannot accept electronic signatures. Signature Phone Number Date American LegalNet, Inc. www.FormsWorkFlow.com