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


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

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

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.

Document number F207-114-999
How to get this document
  • Download (25 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 physician, attending provider, change doctor, doctor, injured worker, new doctor, self insurance, self-insurer, transfer of care, Transfer of Care
Alt Language(s) English
Valid dates 12/2012
Contact information Self-Insurance
Websites

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