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Washington F245-417-000: PT/OT Hotline Authorization

Washington therapy clinics fax this request to L&I's Provider Hotline to authorize more physical, occupational or massage therapy visits on a claim. PT and OT visits 13-24 need prior authorization after the first 12, and massage therapy needs it after the 6th visit. The clinic lists visits to date, the number requested and the date range, and L&I faxes back its decision.

Who completes it

The physical, occupational or massage therapy clinic completes and signs it, certifying that the worker is progressing, treatment is for the industrial injury, the referring provider recommends continuing, and the referral, evaluation, chart notes and progress reports are in the claim file.

Submitting and payment

How to submit it
Fax the request to the Provider Hotline; for PT and OT, first fax the most recent Physical Medicine Progress Report to the L&I claim file. The response comes back by fax.
Who pays
Authorized visits are paid under L&I's physical medicine fee schedule, and visits 13-24 are not authorized without this request and the supporting documentation on file.

Good to know

  • Before requesting visits 13-24, the insurer needs the initial evaluation, all daily chart notes, at least one Physical Medicine Progress Report and a referral from the attending provider.
  • For visits 25 and beyond, request utilization review from Comagine Health directly; the hotline response also flags when UR is required.
  • If the response says the claim is self-insured, contact the self-insured employer or its administrator named on the response instead of L&I.
  • New referrals, provider changes, restarting after surgery or treating a new condition do not reset the claim's PT or OT visit count.

Get the official form

Download the current version from the source each time; forms change without notice.

Physical/Occupational/Massage Therapy Provider Hotline Service Authorization Request

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

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.

Frequently asked questions

When do I need the L&I therapy hotline authorization form?

The first 12 PT or OT visits need no authorization if the claim is open and treatment is for an accepted condition. Visits 13-24 require this request once the progress report and attending provider referral are on file. Massage therapy needs authorization after the 6th visit.

Can this form authorize therapy beyond 24 visits?

No. For visits 25 and beyond, L&I's policy directs providers to request utilization review from Comagine Health directly. L&I also warns that requests beyond 24 visits may be denied if a Physical Medicine Progress Report and chart notes are not on file.