Get F245 072 000 Statement For Miscellaneous Services Lni Wa Form

Filling out the F245 072 000 Statement For Miscellaneous Services Lni Wa Form online can be a straightforward process when you know the steps to take. This guide will provide you with clear and concise instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill out the worker information section by providing your claim number, full name (last, first, middle initial), date of injury, home address, social security number (for identification only), and phone number.
3. Complete the provider information section by entering the L&I provider number, provider name, physical address, Federal Tax ID, and phone number of the provider.
4. In the vocational rehabilitation counselor information section, input the referral ID, vocational rehabilitation counselor’s name, and VRC ID, along with the counselor's address and Federal Tax ID.
5. Fill in the billing information section, including the dates of service (from and to), procedure codes, descriptions of services or supplies provided, units, and the associated charges.
6. Check the appropriate box to indicate if the bill is to reimburse the injured worker and remember that receipts are required for reimbursement.
7. Ensure that all fields are completed accurately, then review your entries for correctness.
8. Once you have filled out the form, you can save your changes, download a copy, print the form, or share it as needed.

Take the next step today and complete your forms online for a smoother process.