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Get Wa F245-072-000 2014-2026
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How to fill out the WA F245-072-000 online
Filling out the WA F245-072-000 form online can streamline the process of billing for various services related to workers' compensation. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.
Follow the steps to successfully complete the form.
- Click the ‘Get Form’ button to access the WA F245-072-000 form and open it in your browser's editor.
- In the 'Type of Service' section, check the appropriate box that corresponds to the service you are billing for. If your service is not listed, select 'Other' and specify the type.
- Complete the 'Worker Information' section by entering the required details: Claim Number, Name (Last, First, Middle Initial), Date of Injury, Home Address (not a PO Box), Social Security Number (for identification purposes only), and Phone Number.
- Fill in the 'Provider Information' section with the L&I provider number or NPI, provider name, provider address, your Patient Account Number (optional), Federal Tax ID, and the phone number for inquiry purposes.
- In the 'Billing Information' section, answer the questions about reimbursement to the injured worker and provide additional required information for inpatient services and prescriptions, if applicable.
- For each service rendered, use a separate line to detail: From date of service, To date of service, Place of Service (POS), Procedure Code, Modifier Codes (if applicable), Diagnosis, and a brief description of the services provided.
- Enter the number of hours billed or rates for services, along with the charges for each service and the total charge at the bottom.
- Sign and date the form where indicated. Ensure that both the worker and provider signatures are provided where necessary.
- After completing the form, save your changes, download a copy for your records, and if necessary, print or share the form as required.
Take action now and fill out the WA F245-072-000 online to ensure timely processing of your services.
An L&I claim in Washington state works by providing financial assistance for workers injured on the job. After filing your claim, the Department of Labor & Industries reviews it, determining eligibility and benefits. Understanding the nuances of the process, including the use of forms like WA F245-072-000, can help ensure you navigate your claim effectively and receive the support you need.