Washington attending providers can use this optional Word form to refer an injured worker to physical or occupational therapy, with the emphasis on functional ability, active care and self-reliance. It records the referral purpose, accepted conditions with ICD codes, current work status, employer accommodations, work exposure concerns, contraindications, therapy goals, interventions already tried and the therapy appointment.
Office staff complete the worker, claim manager, therapist and employer details, and the attending provider completes the clinical section and signs. The worker signs the tear-off notice of the appointment.
Download the current version from the source each time; forms change without notice.
PT/OT Referral Form
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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The form itself is optional, but a referral is not: L&I's physical medicine policy says therapy billed under CPT 97010-97799 requires a referral from the worker's attending provider. This form is one way to make that referral and set the functional goals the therapist works toward.
The form asks for follow-up at 2-week intervals on progress toward functional goals, compliance with visits and home activities, and recommendations for further care. Separately, L&I requires a Physical Medicine Progress Report monthly or by the 12th visit, whichever comes first.