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Get F245 072 000 Statement For Miscellaneous Services Lni Wa Form

Name (Last, First, Middle Initial) Date of injury Home address Apt # City ZIP State Social Security No. (for ID only) Phone no. Provider Information (Please print) L&I provider number Provider name Federal Tax ID Address Phone no. City State ZIP Vocational Rehabilitation Counselor Information (Please print) Referral ID Vocational Rehabilitation Counselor Name VRC ID (L&I provider number) Address Federal Tax ID City State ZIP Billing Information From Date of Service To.

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