Free F248-355-000 Power of Attorney for Electronic Remittance Advice - Washington



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State of Washington Department of Labor & Industries Health Services Analysis/MIPS Electronic Billing Unit PO BOX 44263 Olympia WA 98504-4263 Phone: (360) 902-6511 Fax: (360) 902-6192 Email: ebuLni@Lni.wa.gov State of Washington County of ________________ Power of Attorney for Electronic Remittance Advice Power of Attorney for Electronic Remittance Advice KNOW ALL PERSONS BY THESE PRESENT, that the undersigned, _______________________________________ (Name of provider) of ____________________ County, In the State of ____________________________ does hereby make, constitute and appoint _______________________________________ _________________________________________________ (Name of clearinghouse/intermediary) (Clearinghouse L&I provider account number) as attorney in fact for the benefit of the undersigned, and in its name, place and stead f

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State of Washington Department of Labor & Industries Health Services Analysis/MIPS Electronic Billing Unit PO BOX 44263 Olympia WA 98504-4263 Phone: (360) 902-6511 Fax: (360) 902-6192 Email: ebuLni@Lni.wa.gov
State of Washington County of ________________ Power of Attorney for Electronic Remittance Advice

Power of Attorney for Electronic Remittance Advice

KNOW ALL PERSONS BY THESE PRESENT, that the undersigned, _______________________________________ (Name of provider) of ____________________ County, In the State of ____________________________ does hereby make, constitute and appoint _______________________________________ _________________________________________________ (Name of clearinghouse/intermediary) (Clearinghouse L&I provider account number) as attorney in fact for the benefit of the undersigned, and in its name, place and stead for the following purposes: To act as an agent for the undersigned in receiving the undersigned's Industrial Insurance remittance advice by electronic means from the Washington State Department of Labor and Industries Medical Information and Payment System. The remittance advice information will contain itemized detail of bills processed by the Medical Information and Payment System, including billed charges, allowed charges, payable charges, explanation of denied charges or partial payments, and a listing of those bills still in process as of the close of the processing cycle. This Power of Attorney is made effective this _______ day of _____________, 20____.

_____________________________________________ Provider Name ______________________________ L&I Provider Number ______________________________ National Provider Identifier (NPI) Notary Public Subscribed and sworn before me this Date Notary Public in and for Signature Residing at Commission expires
F248-355-000 poa for electronic remittance advice 04-2007

_________________________________________ Provider/Representative Signature

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File Size: 94.9 kB
Pages: 1
File Format: PDF
State: Washington
Category: Government
Author: Forms Management
Word Count: 248 Words, 1,965 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.lni.wa.gov/forms/pdf/248355af.pdf