Free F208-063-000 Medical Request form - Washington

tape here do not staple

PLACE STAMP HERE POST OFFICE WILL NOT DELIVER WITHOUT PROPER POSTAGE

WAREHOUSE DEPARTMENT OF LABOR AND INDUSTRIES PO BOX 44843 OLYMPIA WA 98504-4843

Quantity

Unit of issue

Form

Quantity Unit of issue

Form

each F200-001-000 Getting Back to Work: It's Your Job and Your Future (for patients) each F200-002-000 Attending Doctor's Return-to-Work Desk Reference each F208-063-000 Medical Forms Request (this card) each F242-071-000 Occupational Disease Work History each F242-071-111 Occupational Disease Work Hist (cont) pad F242-079-000 Application to Reopen Claim

each F245-183-000 Provider's Request for Adjustment each F245-299-000 Consultation Referral pad F245-346 Job Mod Asst App - Voc Rehab each F248-011-000 Providers Application & Notice each F248-014-000 Hospital Services Billing Instructions each F248-015-000 Retraining & Job Mod Exp Billing Inst. each F248-021-000 Pharmacy Prescriptions Billing Inst. each F248-036-000 Request for Taxpayer ID# - W-9 each F248-088-000 Home Care Billing Instructions each F248-094-000 HCFA 1500 Billing Instructions each F248-095-000 Miscellaneous Services Billing Instructions each F248-100-000 General Provider Billing Manual each F248-160-000 Statement for Home Nursing Care each F252-001-000 Medical Examiner's Handbook each F252-004-000 Attending Doctor's Handbook each F252-010-000 Medical Treatment Guidelines each F280-018-000 Plan Development: What are my Rights and Responsibilities - English each F280-019-000 Carrying Out Your Vocational Plan: Your Rights and Responsibilities During Plan Implementation - English

each F242-104-000 Worker's Guide/Ind Ins Benefits - Eng each F242-104-999 Worker's Guide/Ind Ins Benefits - Span each F242-130-000 Accident Report each F245-010-000 Statement for Compound Prescriptions pad F245-030-000 Stmt for Retraining/Job Mod Services

each F245-037-000 Case Transfer Card each F245-072-000 Stmt for Miscellaneous Services - single sheet each F245-072-111 Stmt for Miscellaneous Services - CFF each F245-094-034 Med Aid Rules and Fee Schedules - CD each F245-100-000 Stmt for Pharmacy Services - single sheet each F245-100-111 Stmt for Pharmacy Services - CFF each F245-127-000 HCFA 1500 (L&I use only) - snap apart each F245-127-111 HCFA 1500 (L&I use only) - CFF each F245-145-000 Claimant Travel Expense Voucher - Eng each F245-145-999 Claimant Travel Expense Voucher - Span

Complete your request, fold in thirds, tape closed, affix postage and mail to the address at top of form. This is your return mailing label.

ATTN: Company name Mailing address City

Provider No:

Please type or print clearly.

L&I MEDICAL FORMS REQUEST F208-063-000 03-2008

State

ZIP+4