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PT/OT Referral Form

Attending Providers use this form to refer injured workers for physical or occupational therapy to progressively increase activity and exercise, or activity tolerance, develop home or self-care programs, and perform work activity conditioning. Explains to therapists your specific requests and expected follow-up therapy reports.


Transfer of Attending Provider Form for Self Insured Workers Spanish Formulario para Trasferencia de Proveedor Principal para Trabajadores Autoasegurados

Este formulario es utilizado por los trabajadores autoasegurados que desean transferir su cuidado médico. Los trabajadores autoasegurados deben completar este formulario y enviarlo a su empleador o a su Representante de Terceros.


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Transfer of Attending Provider Form for Self Insured Workers

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.


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