Activity Prescription Form Site
 

Ordering the Insurer Activity Prescription Form

Healthcare providers: Keep a supply of APFs in your office for submitting with a report of accident when there are physical restrictions.

The insurer will supply healthcare providers with an APF to complete with their request. Self-insurers or their third party administrators may send customized APFs.

Order online

Healthcare providers: Fill out the order form below and L&I will mail the APFs to you.

Insurer Activity Prescription Order Form
I want to order copies (copies are singles sheets, not pads).

Name:

Phone:

 000-000-0000
Please send them to:

Company:

Attention:

Mailing Address:

City:

State:

Zip:

 00000-0000
 

Order by fax

Healthcare providers: Fax your order to the L&I Warehouse at 360‑902‑4525. Include in your faxed request the following information:

  • "Insurer Activity Prescription Form - F242-385-000".
  • Your name.
  • Your company name.
  • Mailing address.
  • Telephone number.
  • Quantity (copies are singles sheets, not pads).

Call the Provider Hotline 1-800-848-0811 for questions about the APF.


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