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Formulario para trasferencia de proveedor principal para trabajadores autoasegurados

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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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

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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