Washington > Workers Comp > Claims
Transfer Of Care Card F245-037-000 - Washington
| Transfer Of Care Card Form. This is a Washington form and can be used in Claims Workers Comp . |
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To: Department of Labor and Industries Claim No: ____________________________________ Please transfer my case Date (changed health care providers): __________________ ________________________________________________________________________________ From: (Name of provider) ________________________________________________________________________________ To: (Name of new provider) Provider ID # / NPI#: ________________________________________________________________________________ Address of new provider: ________________________________________________________________________________ City: State: Zip: ________________________________________________________________________________ Reason for transfer: ________________________________________________________________________________ Claimant's name: Today's date: ________________________________________________________________________________ Address: ________________________________________________________________________________ City: State: Zip: ________________________________________________________________________________ Claimant's signature: ________________________________________________________________________________ F245-037-000 Transfer of Care Card 09-2012 Index: TCARE Mail to: Department of Labor and Industries Claims Section PO Box 44291 Olympia WA 98504-4291 American LegalNet, Inc. www.FormsWorkFlow.com
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