Transfer of Attending Provider Form for Self Insured Workers

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Title 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.

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.
Keywords attending doctor, attending provider, change doctor, doctor, provider, self insurance, transfer, transfer of care, Transfer of Care
Alt Language(s) Español
Valid dates 11/2012
Contact information Self-Insurance

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