This form can now be submitted electronically (preferred).
After filling in your information, please press the submit button at the end of the form to send it in. You may also send via fax to 360-352-7298.

Member Name 


APTA/PTWA Member Number 


Practice Name 


Email Address 


Telephone Number 


Fax Number 


Involved Insurer (please choose all that apply)
  Medicare
  L & I
  Regence
  Premera
  DSHS
  UMP
  Other (please specify)  |

If not a question regarding a specific insurer, please choose a category below.
  Coding
  Practice standard
  Other (please specify)

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Please enter the reason this question is important to your practice below:

Thank you!