Form BLS700 373 "Radiology Benefit Manager Registration Addendum" - Washington

What Is Form BLS700 373?

This is a legal form that was released by the Washington State Department of Revenue - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2020;
  • The latest edition provided by the Washington State Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form BLS700 373 by clicking the link below or browse more documents and templates provided by the Washington State Department of Revenue.

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Download Form BLS700 373 "Radiology Benefit Manager Registration Addendum" - Washington

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Radiology Benefit Manager Registration Addendum
Radiology Benefit Manager
Form BLS 700 373
Registration Addendum
Business Licensing Service
PO Box 9034
Note: This form can only be submitted with a Business License Application
Olympia WA 98507-9034
from the Business Licensing Service.
360-705-6741
BLS@dor.wa.gov
Fax: 360-705-6699
To register:
Complete and submit the Business License Application and this Radiology Benefit Manager Addendum.
Provide your company’s Federal Employer Identification Number (FEIN) on the first page of the Business
License Application if one has been issued by the Internal Revenue Service.
Pay a registration fee of $200 in addition to the application processing fee. See
dor.wa.gov/blsprocessingfees
for instructions on how to determine your processing fee.
Radiology Benefit Manager Medical Director:
Please provide the name, and phone number of the Medical Director of your Radiology Benefit Manager business.
Print name (first, middle, last):
Phone:
A Radiology Benefit Manager Registration is required for any person or company conducting business in
Washington or with Washington customers when the business is owned by a third party payor or a carrier, as
defined in RCW 48.43.005, or contracts with a third party payor or carrier in order to:
Process claims for services and procedures performed by a licensed radiologist or advanced diagnostic
imaging service provider.
Pay, or authorize payment to radiology clinics, radiologists, or advanced diagnostic imaging service
providers for services or procedures.
To ask about the availability of this publication in an alternate format for the visually impaired, please call
360-705-6705. Teletype (TTY) users may use the WA Relay Service by calling 711.
BLS 700 373 (12/1/20)
Page 1
Radiology Benefit Manager Registration Addendum
Radiology Benefit Manager
Form BLS 700 373
Registration Addendum
Business Licensing Service
PO Box 9034
Note: This form can only be submitted with a Business License Application
Olympia WA 98507-9034
from the Business Licensing Service.
360-705-6741
BLS@dor.wa.gov
Fax: 360-705-6699
To register:
Complete and submit the Business License Application and this Radiology Benefit Manager Addendum.
Provide your company’s Federal Employer Identification Number (FEIN) on the first page of the Business
License Application if one has been issued by the Internal Revenue Service.
Pay a registration fee of $200 in addition to the application processing fee. See
dor.wa.gov/blsprocessingfees
for instructions on how to determine your processing fee.
Radiology Benefit Manager Medical Director:
Please provide the name, and phone number of the Medical Director of your Radiology Benefit Manager business.
Print name (first, middle, last):
Phone:
A Radiology Benefit Manager Registration is required for any person or company conducting business in
Washington or with Washington customers when the business is owned by a third party payor or a carrier, as
defined in RCW 48.43.005, or contracts with a third party payor or carrier in order to:
Process claims for services and procedures performed by a licensed radiologist or advanced diagnostic
imaging service provider.
Pay, or authorize payment to radiology clinics, radiologists, or advanced diagnostic imaging service
providers for services or procedures.
To ask about the availability of this publication in an alternate format for the visually impaired, please call
360-705-6705. Teletype (TTY) users may use the WA Relay Service by calling 711.
BLS 700 373 (12/1/20)
Page 1