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Physical Therapy / Occupational Therapy Progress Report to Claim Managers

The physical / occupational therapist uses this report to identify the clinical goals and return to work objectives of the injured worker.



Form
F245-059-000
 
Occupational or Physical Therapy Treatment Authorization Fax Request

Used by a therapy provider/clinic to request authorization for outpatient occupational or physical therapy services for L&I claims.



Form
F248-055-000
 
Massage Therapy Treatment Authorization Fax Request

Used by a licensed massage practitioner/clinic to request authorization for outpatient massage therapy services for L&I claims.



Form
F248-357-000
 
Performance Based Physical Capacities Evaluation

Used by occupational and physical therapy providers as an optional reporting format for a Performance-based Physical Capacities Evaluation.



Form
F245-023-000
 
Chronic Opioid Request Form

Use this form to request opioid coverage beyond 12 weeks from the date of injury or surgery, or every 90 days for chronic opioid therapy.



Form
F252-091-000
 
Opioid Treatment Agreement

Use this treatment agreement when starting chronic opioid therapy. It should be renewed yearly or when there is a new prescriber.



Form
F252-095-000

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