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Lni. wa.gov/FormPub/Detail.asp DocID 2467 NOTE Beginning Jan. 1 2013 injured workers will need to get ongoing care from a medical provider who is part of the L I Medical Provider Network. Indicate -- M Male F Female 12B. Dependents -Number of dependents under age 18 does not include spouse/domestic partner. WORKER S TELEPHONE NO. 4. MAILING ADDRESS 5. SOCIAL SECURITY NUMBER 10903 Gravelly Lake Drive SW CITY STATE Lakewood ZIP WA 98499 6. SEX 12A. MARITAL/REGISTERED DOMESTIC PARTNERSHIP STATUS...
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How to fill out providers initial report
How to fill out providers initial report
01
Start by gathering all the necessary information about the provider.
02
Make sure you have all the required forms and documents.
03
Fill out the contact information section first.
04
Provide details about the provider's background and experience.
05
Include information about any certifications or licenses the provider holds.
06
Document the provider's areas of expertise and specialization.
07
Provide a detailed description of the services the provider offers.
08
Include information about the provider's pricing and payment methods.
09
Fill out any additional sections or forms required by the reporting agency.
10
Double-check all the information for accuracy and completeness before submitting.
Who needs providers initial report?
01
Organizations or agencies that require information about a specific provider.
02
Healthcare facilities or hospitals that need to verify a provider's credentials.
03
Insurance companies that need to evaluate a provider's qualifications.
04
Government agencies involved in regulating or licensing providers.
05
Any individual or entity considering engaging the services of a provider.
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