Workers' comp, Paid Family and Medical Leave, parking and reduced fare, Apple Health, DSHS, immunization, POLST and Death with Dignity forms from Washington agencies.
Washington issues a long list of clinician forms, and 30 of them come from Labor & Industries (L&I), led by the Activity Prescription Form. Outside L&I, practices see the Paid Family & Medical Leave certifications from the Employment Security Department, such as the Certification of Birth and the Medical Certification, the DOL Disabled Parking Application (420-073), the Regional Reduced Fare Permit application for Puget Sound transit and the DOH Certificate of Immunization Status. This hub lists 78 forms in all.
Paid Leave certifications are bilingual English and Spanish, go back to the patient within 7 calendar days, and can't carry a fee. The 420-073 needs the form section plus a separate original signed authorization, and the reduced fare permit takes original signatures only. Deaths are certified in WHALES within 5 days. DSHS pays for the 13-021 physical evaluation when chart notes are attached. 23 forms have a Spanish version. Vero Documents fills PDF forms from the visit note and the chart, and the clinician reviews and signs.
F207-028-000Provider's report of initial treatment for an industrial injury or occupational disease on a self-insured employer's claim.
Opens a State Fund workers' compensation claim; the worker and the treating provider each complete a portion at the first visit.
F242-385-000Communicates the injured worker's work status, physical capacities and restrictions, time-loss certification and treatment plan.
Asks L&I to reopen a closed industrial injury or occupational disease claim because the accepted condition has objectively worsened.
Records the independent medical examiner's estimate of the worker's physical capacities when L&I asks for it as part of an IME.
Requests claim-manager authorization for services that require prior approval on a State Fund claim.
F245-058-000Standard report structure L&I expects for an independent medical examination report.
Requests authorization for additional therapy visits beyond the initial allowance.
F245-453-000Therapist's progress report on functional gains, work status and plan, sent to the attending provider and L&I.
F252-098-000Refers an injured worker for a medical opinion, specialty/surgical consultation, concurrent care, transfer-of-care consultation or closing exam and impairment rating.
F252-099-000Attending provider's referral of an injured worker for physical or occupational therapy with functional goals.
F242-208-000Applies for loss of earning power (partial wage replacement) benefits; the attending physician certifies the worker's medical restrictions.
F242-243-000Notifies L&I that the provider diagnosed an occupational disease or infection and advised the worker of the right and deadline to file a claim.
Requests authorization for a prosthetic device for an injured worker.
F245-413-000Attending provider's referral of an injured worker to L&I's Activity Coaching (graded activity) program.
F245-418-000Requests authorization for hearing aid repairs or purchase of durable medical equipment.
F245-428-000Structured chart note for providers outside the US treating a Washington injured worker.
Requests prior authorization for medical services by a provider outside the US.
Worksheet for rating permanent partial disability of the thoraco-lumbar/lumbosacral spine under Washington's category system.
F252-007-000Calculates the worker's binaural hearing loss for an occupational hearing loss impairment award.
Worksheet for rating permanent partial disability of the cervical/cervico-dorsal spine under Washington's category system.
F252-091-000Requests coverage of opioids beyond 12 weeks after injury or surgery, or renewal every 90 days for chronic opioid therapy.
F252-095-000Agreement between prescriber and injured worker when starting chronic opioid therapy, renewed yearly or with a new prescriber.
F252-097-000Requests coverage of opioids between 6 and 12 weeks after injury or surgery.
Prior authorization request for buprenorphine transdermal patch on a workers' compensation claim.
Prior authorization for direct-acting antiviral treatment of hepatitis C accepted under a workers' compensation claim.
F252-114-000Authorization request/criteria form for negative pressure wound therapy on a workers' compensation claim.
F252-118-000Requests an exception to L&I's three-day opioid supply limit after a dental procedure.
F252-127-000Prior authorization request for a CGRP antagonist for chronic migraine accepted on a claim.
Prior authorization request for esketamine nasal spray for treatment-resistant depression accepted on a claim.
Certificado de nacimiento
Confirms a birth so the birthing parent can take the first six weeks of medical leave to recover and either parent can take family leave to bond.
Certificado médico
Certifies the employee's own serious health condition, its start date and expected duration/frequency of incapacity for Washington paid medical leave.
Certificado de permiso familiar
Certifies that the employee's family member has a serious health condition and needs care, with expected duration, for Washington paid family leave.
Certificado médico de cuidado prenatal
Certifies the need for medical leave for prenatal care or pregnancy-related incapacity under Washington paid medical leave.
Lets a health care provider designate an authorized representative for a patient who cannot complete Paid Family & Medical Leave administrative requirements or designate one themselves, attesting it is in the patient's best interest.
Certificado médico por complicaciones en el parto
Certifies a need for more than six weeks of medical leave to recover from giving birth, or leave for birth complications.
Medical provider's written recommendation after cholinesterase testing of a pesticide handler (removal from exposure or return to work).
DR-500-033Informe del examen de la vista
Ophthalmologist or optometrist reports acuity, fields, eye conditions and recommended re-exam frequency when DOL has reason to believe a driver's vision may affect safe driving.
Certifies a disability against the RRFP Medical Eligibility Criteria so the applicant gets a reduced-fare ORCA card valid on regional transit (King County Metro, Sound Transit, Community Transit, Pierce Transit, Kitsap Transit, Everett Transit, WSF).
Healthcare provider certifies a qualifying condition and whether disabled parking should be permanent (5 years) or temporary (up to 12 months) for placards, plates or tabs.
Healthcare professional's co-signature and approval of an ADA paratransit (Access) eligibility application in King County, WA; the application is incomplete without it.
HCA 13-835Required first page for any Apple Health fee-for-service medical, DME or dental prior authorization or limitation extension request faxed to HCA.
HCA 13-835AFee-for-service Apple Health pharmacy prior authorization or limitation request for a prescription.
HCA 13-847Requests Apple Health authorization for home health skilled nursing and therapy visits.
Medical justification to exceed Apple Health quantity limits for incontinence supplies.
Prescriber's order and medical justification for oral enteral nutrition products for Apple Health clients.
HCA 13-747Clinical evaluation supporting Apple Health authorization of a hospital bed.
HCA 13-772Requests Apple Health authorization for hearing aids and related services.
Sample form for the licensed healthcare provider's request and parent authorization required before school staff give medication (RCW 28A.210.260).
Recommended preparticipation physical exam and medical clearance for Washington interscholastic athletics; the eligibility form goes to the school.
DOH 348-013Certificado del Estado de Vacunación (CIS)
Required record of a child's vaccinations for Washington school/child care, including a provider-signed section verifying chickenpox history or lab immunity.
DOH 348-106Certificado de Exención
Official state-seal form to exempt a child from school, child care or preschool vaccines for personal/philosophical or religious reasons (page 1, with practitioner counseling declaration) or medical reasons (page 2, practitioner-certified).
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
DOH 961-135Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Portable medical order for CPR, treatment intensity and nutrition for seriously ill or frail Washingtonians, honored by EMS.
Web system in which medical providers, medical examiners and coroners must register and complete the medical portion of Washington death and fetal death records.
Documents the attending qualified medical provider's compliance with the Washington Death with Dignity Act when a lethal-dose prescription is written.
Consulting provider confirms diagnosis, prognosis, competence and voluntariness of a patient requesting medication under the Death with Dignity Act.
Psychiatric or psychological provider reports whether a Death with Dignity patient's judgment is impaired by a mental disorder.
Reports the death and circumstances after a patient who received a Death with Dignity prescription ingests it or dies of another cause.
Designated crisis responder's petition for emergency initial detention (up to 120 hours) of a person with a behavioral health disorder under RCW 71.05.153 / 71.34.
Petition for 14-day, 90-day or less-restrictive-alternative (outpatient) involuntary treatment under RCW 71.05 for a mental and/or substance use disorder.
Designated crisis responder's petition asking the court for a non-emergency order of initial detention for evaluation and treatment (RCW 71.05.150).
Practitioner's authorization that a patient with a qualifying condition may benefit from medical cannabis; basis for registry entry/recognition card, plant counts and compassionate-care renewal.
Provider report of a diagnosed sexually transmitted infection (syphilis, gonorrhea, chlamydia, etc.) with treatment and partner information.
Report of suspected abuse, neglect, abandonment or financial exploitation of a vulnerable adult to Adult Protective Services.
DOH 150-002Provider case report of HIV infection or AIDS in an adult or adolescent for state HIV surveillance (eHARS).
DSHS 14-264Application for the TED program; a professional certifies the applicant's hearing loss or speech disability and that the requested equipment will help.
REV 64 0095Doctor certifies the date a person became disabled and whether they can engage in substantial gainful activity (and until when, or permanently) for the senior citizen and people with disabilities property tax exemption/deferral.
Physician (MD, ARNP or PA) certification of a permanent mobility, visual or developmental disability for WDFW Disability Status (companion card, designated harvester, reduced-fee licenses, special use permits).
Physician's medical certification of a permanent inoperable physical or cognitive disability that prevents boarding/exiting a vehicle, for a Special Use Permit to hunt from a motor vehicle (requires WDFW Disability Status).
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
No. ESD says providers cannot charge a fee for completing the Paid Family & Medical Leave forms: the Medical Certification, Family Leave Certification, Certification of Birth, Prenatal Care Medical Certification and Medical Certification for Birth Complications. Return the completed form to the patient within 7 calendar days, and the patient uploads it to their Paid Leave account. Each form is a bilingual English and Spanish PDF.
Two things: the healthcare provider section on page 2 of the 420-073, and a separate original signed authorization, such as an original prescription. Copies are not accepted. A doctor or licensed registered nurse practitioner certifies the qualifying condition and whether parking should be permanent (5 years) or temporary (up to 12 months); DOL's web page also lists physician assistants. False certification can bring sanctions under RCW 18.130.
A Washington-licensed physician (MD or DO), psychiatrist, psychologist (PhD), PA, ARNP or ASHA-certified audiologist. The provider completes the certification of eligibility on the back and enters the RRFP medical eligibility criteria number. The form is marked original signature only, with no photocopies or faxes. The applicant presents it at a customer service office or uploads it to the Reduced Fare Portal. The permit works on King County Metro, Sound Transit and the other Puget Sound agencies.
The attending provider files the DOH 422-064 within 30 calendar days of writing the prescription, and the DOH 422-068 within 30 days of ingestion or death from another cause. The consulting provider completes the DOH 422-065 right after the exam, and a psychiatric or psychological provider completes the DOH 422-066 only when a mental health evaluation was done. Since the 2023 amendments, ARNPs and PAs can act as qualified medical providers. Forms go to DOH by REDCap, fax or mail.