Dear Provider:
Thank youfor your interestintheCenters ofOccupational HealthEducation(COHE) Program.This
Supplemental Application describes requirementsofparticipation.
Background
TheCOHE Program is apartnershipbetweentheDepartment ofLabor &Industries(L&I ordepartment),medical, andcommunity resources,aimed atimprovinginjuredworker healthoutcomes.TheCOHEs arededicatedto expandingcommunityexpertisein bothoccupational healthcareand disability prevention.
Billing Information
COHEHSCs are allowedtousespecial billingcodes asoutlinedintheCOHEFeeSchedule.Department approval ofthis Supplemental Applicationdoes notguaranteepaymentofall services billed.Thedepartment’s “General Provider BillingManual”provides instructionsfor bill submission.Thedepartmentwill purchaseonly coveredservices, providedby covered professionals.
TheHSC agreesto:
1) serve as facilitatorandcoordinator among provider, employer,patient,union(whenapplicable),andclaim manager,and,
2) provideappropriateclaim-relateddocumentationtothedepartmentinatimely manner,and,
3) usethe COHEProgram Fee Schedule, and
4) refer to the COHE contract for data security requirements.
AnHSC will beheldtotheterms ofthisapplication,eventhoughathirdparty maybeinvolvedinbillingclaims to thedepartment.
Thedepartmentreserves therighttodeny, revoke,suspend, or conditiona HSCsauthorizationtoparticipatein theCOHEProgramatany time. Thedepartment or theprovider may terminatethisapplicationatany time by submittinganoticeofterminationinwritingtothelocalCOHE.
Statement of Agreement
I, Enter Full Name, agreeto abide bytheterms of thisapplication and all applicable federalandWashington State statutes, rules, andpolicies.
L&IProviderNumberClick or tap here to enter text. / GroupNumber
Click or tap here to enter text.
NameofCOHE
Click or tap here to enter text. / Email Address
Click or tap here to enter text.
Email (optional)
Signature / Date Click or tap to enter a date.
Completed forms can be faxed to 360-902-6515 or emailed to