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Washington Power of Attorney for Electronic Remittance Advice Form


Washington Power of Attorney for Electronic Remittance Advice Form
Washington Power of Attorney for Electronic Remittance Advice Form
F248-355-000 poa for electronic remittance advice 04-2007
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: [email protected]
Power of Attorney for
Electronic Remittance Advice
State of Washington
County of ________________
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 Provider/Representative Signature
______________________________
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
RESET
Washington Power of Attorney for Electronic Remittance Advice Form