Provider Accounts Change Form
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Provider Accounts Change Form. This is a Washington form and can be use in Claims Workers Comp.
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Tags: Provider Accounts Change Form, F245-365-000, Washington Workers Comp, Claims
Mail to: L&I Provider Accounts
PO Box 44261
Olympia, WA 98504-4261
Provider Account
Change Form
Phone 360-902-5140
Fax 360-902-4484
Use this form to notify L&I of any change to your provider account information. Send to address above.
Important: We will need: 1.) Provider Account name 2.) Federal tax ID # 3.) L&I provider number and
4.) Your signature at the bottom.
Account information
Provider Account Name:
Federal Tax ID:
L&I Provider # for individual:
L&I Provider # for group:
Change the name on my account
(If you are changing the name of an individual, you must attach documentation: Practice license, marriage
license, divorce decree, or court order. You do not need documentation to change your business name.)
Current Provider Name:
New Provider Name:
Change the address of my office’s physical address
(This is the physical location where you provide services. It cannot be a PO Box.)
Current Physical Address
New Physical Address
Address
Address
City
State
ZIP
Phone:
City
State
ZIP
Phone:
Change my billing address Check if you want us to send all mail here.
(This is where you want L&I to mail your payments.)
Current Billing Address
New Billing Address
Address
Address
City
State
ZIP
Phone:
City
State
ZIP
Phone:
Inactivate my L&I account
Provider Number:
Provider Name:
Effective Date:
Reason:
I authorize this change by signing below:
Date:
Signature:
Phone:
Important: Completing this form will not update your tax information with L&I.
F245-365-000 Provider Accounts Change Form 10-10
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