Get F245-046-000 - Ime Provider Account Application

The F245-046-000 - IME Provider Account Application is essential for practitioners wishing to provide services as Independent Medical Exam (IME) providers in Washington State. This guide will assist you with clear, step-by-step instructions to complete the form online effectively.

Follow the steps to complete the IME Provider Account Application.

1. Click the ‘Get Form’ button to access the IME Provider Account Application and open it in the online form editor.
2. Fill out section A (Application Information), indicating whether you are applying as an individual examiner or a firm, and provide your location information.
3. Complete section B (Tax Reporting Information) by entering your taxpayer identification number, which must match the W-9 form you will submit.
4. In section C (Payee Account and Billing Information), provide your business name, contact person's details, physical location, and billing address.
5. Proceed to section D (Practitioner Information) and input your name, license type, medical specialty, date of birth, and contact information.
6. Complete section E (NPI Information) by entering your National Provider Identifier (NPI) numbers.
7. In section F (Medical Qualifications), attach the required certifications and provide any necessary documentation regarding your qualifications.
8. Answer the questions in the IME Attestation section honestly, providing any necessary explanations for answers that require further detail.
9. Review the completed form thoroughly to ensure all sections are filled out correctly and that any required documentation is attached.
10. Save changes, download a copy of your application, and prepare for submission by printing or sharing the form as needed.

Complete your F245-046-000 - IME Provider Account Application online now to begin your application process.