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

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

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

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

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

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