F245 072 000 2026

1. Click ‘Get Form’ to open the f245 072 000 in the editor.
2. Begin by selecting the type of service you are billing for. Check the appropriate box, and if your service is not listed, select 'Other' and specify.
3. In the Worker Information section, fill in the claim number, worker's name (last, first, middle initial), date of injury, home address (not a PO Box), Social Security Number for ID verification, and phone number.
4. Next, complete the Provider Information section with your L&I provider number or NPI, provider name, address, patient account number (optional), Federal Tax ID, phone number for inquiries, referring physician's name and their provider number/NPI.
5. In the Billing Information section, indicate if this bill is for reimbursement to the injured worker. If applicable for glasses or inpatient services, provide additional details as required.
6. List each service provided with corresponding dates of service, place of service code (POS), procedure code (Proc Code), diagnosis code, description of services rendered, and charges.
7. Finally, ensure both worker and provider signatures are included where required before submitting your completed form.

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