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Fillable Physicians Initial Report
PIR
PIR
Handle: Document-81096
Owner: Conti, Linda (User-3767, 10557:EVERETT)DS
Friday, August 19, 2016 11:20:06 AM PDT
Friday, August 19, 2016 11:20:48 AM PDT
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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
FILLABLE PIR.pdf
No
4
108461
No
Appears In: EMPLOYEE ON-THE-JOB INJURY FORMS
Preferred Version: Fillable Physicians Initial Report