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How do I fill this out?
To fill out this application, gather all required documents and follow the checklist carefully. Ensure all information is accurate and complete. Check for signatures and dates as per the instructions.
How to fill out the Washington State L&I Medical Provider Application?
1
Gather all required documents as outlined in the checklist.
2
Complete the Washington Practitioner Application with accurate information.
3
Fill out the Provider Agreement, ensuring all statements are correct.
4
Sign and date all forms where required.
5
Submit all documents together to the provided address.
Who needs the Washington State L&I Medical Provider Application?
1
Medical providers looking to join the L&I Medical Provider Network.
2
Physicians seeking credentialing for services under L&I.
3
Healthcare organizations needing to submit applications for multiple providers.
4
Administrative staff responsible for managing provider applications.
5
Provider networks coordinating credentialing on behalf of individual providers.
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What are the instructions for submitting this form?
To submit the L&I Medical Provider Application, gather all completed forms and required documents, including the Washington Practitioner Application, Provider Agreement, and IRS W-9. Send the completed packet to the Washington State Department of Labor & Industries at PO Box 44261, Olympia WA 98504-4261, or fax to 360-902-4563. For any questions, contact the Provider Network team at ProvNet@Lni.wa.gov.
What are the important dates for this form in 2024 and 2025?
For the years 2024 and 2025, keep an eye on any updates from the Washington State Department of Labor & Industries regarding the Medical Provider Network application deadlines and requirements. Staying updated will help ensure timely submissions and avoid any processing delays.
What is the purpose of this form?
The purpose of this form is to facilitate the credentialing of medical providers within the L&I Medical Provider Network. It ensures that all necessary documentation is collected to comply with state regulations and to streamline the processing of medical claims. By completing this application accurately, providers can ensure timely payment for services rendered.
Tell me about this form and its components and fields line-by-line.
- 1. Washington Practitioner Application: A detailed application form that requires personal, educational, and professional information.
- 2. Provider Agreement: An agreement outlining the terms of service and responsibilities within the network.
- 3. Credentialing Checklist: A checklist to ensure all required documents are submitted for a complete application.
- 4. IRS Form W-9: A tax form needed for payment processing and accurate tax reporting.
- 5. Current Malpractice Insurance Face Sheet: Proof of current malpractice insurance coverage for the provider.
What happens if I fail to submit this form?
Failure to submit this application correctly can lead to delays in your credentialing process and potential loss of services under the L&I network. Incomplete or inaccurate submissions may result in rejection and necessitate resubmission, causing further delays in payments.
- Incomplete Applications: Missing required documents will delay the review process.
- Incorrect Information: Errors in the application can lead to rejection or request for resubmission.
- Failure to Sign: Not providing a signature where required can invalidate your submission.
How do I know when to use this form?
- 1. Initial Credentialing: Use this form for the first-time application to join the L&I network.
- 2. Changes in Practice: Submit when there are significant changes in your practice or ownership.
- 3. Provider Transfers: Use this for transferring existing credentials from another provider network.
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