Washington medical providers use this notice after diagnosing a worker with an occupational disease or infection when no claim form is completed at that visit. The provider certifies the diagnosis, tells the worker of the right to file a workers' compensation claim, and explains that a claim must be filed within two years from the date the form is signed and a copy is given to the worker.
The examining provider completes the medical section (provisional diagnosis with ICD code, date of first treatment, provider number and type of exposure), and a licensed physician must sign. The worker helps complete the worker, employer and exposure section.
Download the current version from the source each time; forms change without notice.
Notice of Occupational Disease or Infection
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It documents that a provider diagnosed an occupational disease or infection and told the worker of the right to file. The worker must then file a claim within two years from the date the form is signed and a copy is provided, so handing the worker a copy is part of the process.
The form says a licensed physician must sign. The signer certifies having examined the worker, determined that the disease or infection was caused by the occupation, and advised the worker of the right to file a claim and of the two-year filing limit.