Washington providers send this request when a State Fund workers' compensation service needs claim manager preauthorization. For up to two diagnosis and procedure pairs, it lists codes, whether the diagnosis is currently allowed, side of body or tooth number, purpose, estimated dates and a short causal-relationship explanation. Objective medical documentation, such as chart notes or test results, is attached to support coverage.
The requesting provider, whether attending, consulting or other, or the office staff complete the whole form, including the L&I provider ID or NPI and a staff contact at the office.
Download the current version from the source each time; forms change without notice.
Preauthorization Request for Services for State Fund Workers' Compensation Patients
This form is a Word template, not a PDF. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.
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.
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Not when the service needs utilization review. The form says not to use it for UR handled by Comagine and gives inpatient surgery and MRIs as examples. Check L&I's Authorization & Referral Fee Schedule tool to see whether a service requires UR or claim manager preauthorization.
No. The form is titled for State Fund workers' compensation patients and goes to the L&I claim file. For claims of self-insured employers, contact the employer or its third-party administrator about their authorization process.