Activity Prescription Form for Washington Injuries
This form is used by healthcare providers to detail the work capacities and restrictions for workers recovering from injuries. It helps in planning modified duties and treatment. Workers and employers can use this form to communicate and ensure a smooth recovery process.
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How do I fill this out?
First, gather all necessary information including patient's name, ID, and injury details. Fill out the form sections as per the instructions. Ensure to note any work restrictions or modified duties and sign the form.
How to fill out the Activity Prescription Form for Washington Injuries?
1
Gather all necessary information including patient's name, ID, and injury details.
2
Fill out the form sections as per the instructions.
3
Note any work restrictions or modified duties.
4
Sign and date the form.
5
Submit the form to the relevant department.
Who needs the Activity Prescription Form for Washington Injuries?
1
Healthcare providers need this form to document patient’s work capacities and restrictions.
2
Injured workers need this form to communicate their medical status to their employers.
3
Employers need this form to plan for worker’s modified duties.
4
Self-insured employers or third-party administrators need this form to process claims.
5
Claim managers need this form to update and manage the worker’s claim.
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What are the instructions for submitting this form?
Submit the form promptly to the relevant department to avoid delays. For state fund claims, send the form to the Department of Labor and Industries at PO Box 44291, Olympia WA 98504-4291, or fax it to 360-902-4567. For self-insured claims, contact the self-insured employer or third-party administrator for submission instructions. Always keep a copy of the submitted form for your records.
What are the important dates for this form in 2024 and 2025?
Ensure to submit this form promptly. Note relevant injury dates and follow-up appointments.
What is the purpose of this form?
The purpose of this form is to document the medical status and work capacities of workers who have been injured. It helps in planning modified duties that suit the worker’s current health condition. Furthermore, it assists employers, healthcare providers, and claim managers in tracking the recovery process.
Tell me about this form and its components and fields line-by-line.
- 1. State Fund Claim: Details about the state fund claim and contact information.
- 2. Worker's Name: The patient's name who has been injured.
- 3. Patient ID: The unique identification number of the patient.
- 4. Visit Date: The date of the visit related to the injury.
- 5. Claim Number: The claim number assigned to the injury case.
- 6. Medical Status: Details on the worker's medical status and capacities.
- 7. Work Capacities: Information on what tasks the worker can perform and any restrictions.
- 8. Plan: Future plans for treatment, surgery, or rehabilitation.
- 9. Signature: Signature fields for authorizing the information in the form.
What happens if I fail to submit this form?
Failure to submit this form can result in delayed recovery planning and claim processing.
- Delayed Recovery: Without the form, adjusting work duties becomes difficult, hindering recovery.
- Claim Processing: The claim cannot be processed efficiently without adequate documentation.
- Communication Gaps: Not submitting the form leads to miscommunication between healthcare providers and employers.
How do I know when to use this form?
- 1. Injury Occurs: Document the initial medical status and capacities.
- 2. Work Restrictions Needed: Specify any modified duties suitable for the worker.
- 3. Claim Submission: Submit the form as part of a claim for the injury.
- 4. Follow-Up Visits: Update medical status and work capacities after each follow-up.
- 5. Final Recovery: Document full recovery and return to normal duties.
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