Washington L&I uses this two-page form for preauthorization and each 30-day continued authorization of negative pressure wound therapy on a workers' compensation claim. It documents a complete wound therapy program tried and failed, wound location, size, depth, tunneling and drainage, wound type, FDA safety contraindications and recent labs. Current dated wound photos and the physician's prescription must accompany it.
The nursing staff caring for the worker, at a nursing facility, nursing service or home health agency, complete the entire form for preauthorization and sections I, III and V for each 30-day review. The prescribing provider is identified in section I.
Download the current version from the source each time; forms change without notice.
Negative Pressure Wound Therapy
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The nursing staff caring for the worker, whether at a nursing facility, nursing service or home health agency. They complete the whole form for preauthorization. The prescribing provider is named on it with their L&I provider ID, and their prescription is attached along with photos and recent notes.
Complete sections I (worker information), III (wound evaluation) and V (contraindications), and include current, dated color wound photos showing a measurement tool and the physician's prescription. All information must be current within 30 days of the service date.