Last updated: 10/24/2024
Provider Account Application {F248-011-000}
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Description
F248-011-000 - PROVIDER ACCOUNT APPLICATION. The form is used for healthcare providers or facilities to apply for a provider account with the Washington State Department of Labor & Industries (L&I). This account allows providers to deliver healthcare services to injured workers or crime victims, and to bill L&I for those services. The form collects business and personal information, including tax IDs, physical location, payment addresses, licensure details, and certification information. It includes an agreement section where providers agree to comply with state laws, billing guidelines, opioid treatment rules, and the L&I provider network standards. www.FormsWorkflow.com
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