Washington > Workers Comp > Claims
Consultation Or Referral F245-299-000 - Washington
| Consultation Or Referral Form. This is a Washington form and can be used in Claims Workers Comp . |
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Department of Labor and Industries Claims Section PO Box 44291 Olympia WA 98504-4291 CONSULTATION OR REFERRAL Do not request any of the following services if an IME has been ordered. Attending Provider--Attach a copy of all authorizations you have received for this referral and send them with this form to the consultant. Send a copy of the entire form to L&I. Give the bottom portion of this form to the patient. This is a communication tool, optional. Consultant: To review the claim file, contact the claim manager to obtain temporary access to the Claim &Account Center. Appointment made with: (Name and credential. Must be in the L&I Medical Provider Network) On (Date): At (Time): Claim # Reason: (Mark all that apply) Second opinion for: Diagnosis Treatment plan Concurrent care 120 days of conservative care Consider transfer of care Surgical consult Consult with impairment rating (To serve as a closing exam. Claim manager authorization provided on an APF or in writing, attached.) DOI: Date of first treatment, if known: Worker's name: Occupation: History of injury and/or attach a copy of accident report: Accepted condition: (Diagnosis) Pertinent test results: Lab, imaging, x-ray, others--(Attach copies) Currently on time loss? Currently on work restrictions? (Attach latest APF, if available) Care provided to date: Yes Yes No No Progress to date: (Include change in subjective & objective findings compared to onset of accepted condition.) Claim manager's name: Requested by: (Attending provider' name) Phone number: If necessary: Claim manager informed Claim manager approved On (Date) Give this portion to the claimant** An appointment has been made with: (Name, Address) Office phone: Date: Time: **I understand that failure to complete this consultation or referral may jeopardize further benefits on my claim. Doctor's specialty (Claimant's signature) F245-299-000 consultation referral 05-2012 American LegalNet, Inc. www.FormsWorkFlow.com
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