Health care providers outside the United States who treat a worker with an open Washington workers' compensation claim document their services on this L&I chart note. It records patient and provider details, visit dates and diagnoses, evaluation or treatment notes, other services, and itemized charges in local currency. Sections 1-3 and 5-6 are required at billing, and a complete form can replace a chart note.
The out-of-country treating provider completes and signs it, using a separate form for each evaluation date. Sections 4a, 4b and 4c are completed only when an evaluation, a treatment or another service was provided.
Download the current version from the source each time; forms change without notice.
Medical Chart Note for Out of Country Providers
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Sections 1-3 (patient, provider and visit details) and 5-6 (charges and certification) are required for all services, and L&I says incomplete documentation at billing will result in payment denial. Sections 4a, 4b and 4c are completed only for evaluations, treatment or miscellaneous services such as equipment.
Enter your usual and customary charge, the amount you charge any patient locally, and include the currency type on each line and on the total. L&I applies the currency conversion rate for the date of service, and its out-of-country fee schedule maximums are listed in US dollars.
Yes. L&I publishes a Spanish version as F245-428-999, and the companion preauthorization request also has a Spanish edition. L&I's out-of-country policy says the insurer is responsible for translating documentation into English, though translated documents can speed up some services.