Transfer of Attending Provider Form for Self Insured Workers


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Title Transfer of Attending Provider Form for Self Insured Workers
Description

This form is used by self-insured injured workers who want to transfer their medical care.  Self-insured workers should complete the form and send it to their employer or their Third Party Representative.

Document number F207-114-000
How to get this document
  • Download (48 KB MS Word .doc) 
  • Call the Self-Insurance Section of L&I, 360-902-6898 or fax your request to 360-902-6977. Please have the document number ready so we can process your request quickly. The title is also helpful.
Alt Language(s) Español
Valid dates 11/2012
Contact information Self-Insurance
Websites

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