Notice of appeal

Washington State Provider Appeal

The Board of Industrial Insurance Appeals' electronic filing system is designed to simplify and speed the process of filing an appeal. A provider has the right to file an appeal with the BIIA from decisions of the Department of Labor and Industries regarding a provider's eligibility to provide services to industrially injured workers. See RCW 51.52.060. Generally, you must file an appeal with the BIIA within 60 DAYS of receiving L&I's decision if L&I has denied your enrollment or removed or suspended you from the health care provider network. Please refer to the L&I decision for specific deadlines and additional information. If you disagree with a decision made by L&I on a claim or payment, use the Workers' Compensation Appeal form.

If you wish to appeal an L&I decision, complete the form below. We will send you a filing confirmation to the email address you provide. It is not necessary to send a paper copy of the appeal.

Public disclosure: Please note that information provided in an appeal may be subject to public disclosure under RCW 42.56.070(1).

Customary office hours: Documents received after 5 p.m. will be deemed filed the next business day.

Before filing your appeal: Please see WAC 263-12-050 and RCW 51.52.070. Please view our appeal process videos to better understand the appeal process. You can access the videos here.

Warnings:
(1) You have 15 minutes to complete this form. A warning will appear with 2 minutes left. Click continue or all your data will be lost and must be reentered.
(2) You must enter an email address to receive an email confirmation of successful submission.
(3) Unless you see "Your notice of appeal form has been submitted" your electronic application has NOT been received by the BIIA.

*: required fields  help: to display detail information  

Appeal type selection

Appeal filed By:*  
Appeal filed on behalf of:*