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Physicians Initial Report Form
First L & I Visit Form

Form that is filled out by the doctor on a first visit for an L & I claim. 

PIR
Handle: Document-67720
Owner: Hanson, Jean (User-867, 07736:EVERETT)DS
Thursday, June 18, 2015 08:55:06 AM PDT
Tuesday, January 5, 2016 07:56:49 AM PST
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LanguagePreference English Spanish Russian Korean ChineseVietnamese Laotian Cambodian OtherMAIL TO SELF-INSURED COMPANY PROVIDER’S INITIAL REPORTA Provider’s Initial Report (PIR) completed by the provider and the worker, establishes a claim.
  • Worker’s Signature Date
9.
  • a.
  • Has the worker ever been treated for the same or similar condition? Signature
DONOTSENDTHISFORMTOLABOR &INDUSTRIES12.
  • ATTENDING HEALTH CARE PROVIDER INFORMATION
NOTICE: FAILURE TO FILE THIS REPORT WITHIN5 DAYS FROM THE DATE OF TREATMENT MAYRESULT IN A PENALT...
Allowed
Adobe Portable Document Format (.pdf) - application/pdf
PIR.pdf
No
4
69401
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Appears In: EMPLOYEE ON-THE-JOB INJURY FORMS
Preferred Version: Physicians Initial Report Form