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Fillable Activity Prescription Form
APF
L & I
Handle: Document-81093
Owner: Conti, Linda (User-3767, 10557:EVERETT)DS
Friday, August 19, 2016 11:16:07 AM PDT
Friday, August 19, 2016 11:16:07 AM PDT
Modified By:
Locked By:
  • F242-385-000 Insurer Activity Prescription Form (APF) 07-2009 APF
State Fund Claims: Dept.
  • ?Yes ?No
Modified duty available? ?Yes ?NoDate of contact: ______/______/______ Name of contact:________________________Notes:Note to Claim Manager:New diagnosis:________________________Opioids prescribed for: ? Acute pain or ? Chronic painRequired: Plans Worker progress: ? As expected / better than expected.
  • Choose any number: 360-902-4292 360-902-4565 360-902-4566 360-902-4567
360-902-5230 360-902-6100 360-902-6252 360-902-6460*Self-Insured Claims: For a list ...
Allowed
Adobe Portable Document Format (.pdf) - application/pdf
FILLABLE APF.pdf
No
4
308547
No
Appears In: EMPLOYEE ON-THE-JOB INJURY FORMS
Preferred Version: Fillable Activity Prescription Form