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 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) Form 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 F242-071-000 Occupational Disease Work History each F248-014-000 Hospital Services Billing Instructions each F242-071-111 Occupational Disease Work Hist (cont) each F248-015-000 Retraining & Job Mod Exp Billing Inst. pad each F248-021-000 Pharmacy Prescriptions Billing Inst. F242-079-000 Application to Reopen Claim each F242-104-000 Worker's Guide/Ind Ins Benefits - Eng each F248-036-000 Request for Taxpayer ID# - W-9 each F242-104-999 Worker's Guide/Ind Ins Benefits - Span each F248-088-000 Home Care Billing Instructions each F242-130-000 Accident Report each F248-094-000 HCFA 1500 Billing Instructions each F245-010-000 Statement for Compound Prescriptions each F248-095-000 Miscellaneous Services Billing Instructions pad each F248-100-000 General Provider Billing Manual F245-030-000 Stmt for Retraining/Job Mod Services each F245-037-000 Case Transfer Card each F248-160-000 Statement for Home Nursing Care each F245-072-000 Stmt for Miscellaneous Services - single sheet each F252-001-000 Medical Examiner's Handbook each F245-072-111 Stmt for Miscellaneous Services - CFF each F252-004-000 Attending Doctor's Handbook each F245-094-034 Med Aid Rules and Fee Schedules - CD each F252-010-000 Medical Treatment Guidelines each F245-100-000 Stmt for Pharmacy Services - single sheet each F280-018-000 Plan Development: What are my Rights and Responsibilities - English 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 F280-019-000 Carrying Out Your Vocational Plan: Your Rights and Responsibilities During Plan Implementation - English 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. Please type or print clearly. L&I MEDICAL FORMS REQUEST F208-063-000 03-2008 ATTN: Provider No: Company name Mailing address City State ZIP+4 American LegalNet, Inc. www.FormsWorkflow.com