For workers of Washington self-insured employers, this report completed by the provider and the worker establishes the workers' compensation claim; once the employer receives it, the employer must assign a claim number and adjudicate the claim. The provider records the exam date, ICD diagnoses with side of body, objective findings, causation on a more-probable-than-not basis, work release and light-duty restrictions.
The attending health care provider completes the provider section, and a licensed provider must sign before the report is accepted. The worker completes or supplies the patient information, signs the medical release and acknowledges the statement of responsibility.
Download the current version from the source each time; forms change without notice.
Provider's Initial Report (PIR)
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To the self-insured employer or its service representative, not to Labor & Industries; the form itself prints a reminder not to send it to L&I. The employer then assigns the claim number and adjudicates the claim. Keep the provider copy and give the worker their copy.
The form warns that failing to file within 5 days from the date of treatment may result in a penalty under RCW 51.48.060. L&I's billing policy also pays the report at a higher rate when it is received within 5 business days of the exam date shown on the form.
Only attending provider types with a valid L&I provider number can sign and be paid for these forms. Clinical psychologists (PhD or PsyD) can complete and sign them only when the sole condition on the claim is psychiatric, and a claim that once had a physical condition does not qualify.