Washington attending providers can use this optional form to refer an injured worker for a second opinion, a specialty or surgical consultation, concurrent care, or a closing exam with impairment rating. It lists accepted conditions with ICD codes, work status, attachments and referral reasons, followed by a clinical summary of history, treatment and progress and the key questions for the consultant.
The attending provider completes and signs it; for concurrent care, the AP also states the concurrent provider's role, functional goals and expected duration. The consultant then calls the claim manager for Claim & Account Center access or approval of concurrent care.
Download the current version from the source each time; forms change without notice.
Attending Provider's Referral Form
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.
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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Consultations other than for mental health do not require prior authorization, according to the form. Concurrent care does, so obtain claim manager authorization before scheduling the patient. Impairment rating referrals also need claim manager authorization, and the consultant must be an approved examiner.
No, it is described as an optional communication tool. You can follow its outline in a separate referral letter or send the discussion and summary section from your EHR, as long as L&I and the consultant receive the same information and supporting attachments.