| Location: | Home  Fillable Physicians Initial Report Fillable Physicians Initial Report Properties |
| Location: | Home Fillable Physicians Initial Report Fillable Physicians Initial Report Properties |
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| Fillable Physicians Initial Report | |
| Handle: | Version-73656 |
| Owner: | Conti, Linda (User-3767, 10557:EVERETT)DS |
| Friday, August 19, 2016 11:20:06 AM PDT | |
| Thursday, October 6, 2016 10:04:24 AM PDT | |
| Modified By: | |
| - (Select one) Language Preference English Spanish Russian Korean Chinese Vietnamese Laotian Cambodian Other MAIL TO SELF-INSURED COMPANY PROVIDER’S INITIAL REPORT A 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 DO NOT SEND THIS FORM TO LABOR & INDUSTRIES 12. - ATTENDING HEALTH CARE PROVIDER INFORMATION NOTICE: FAILURE TO FILE THIS REPORT WITHIN 5 DAYS FROM THE DATE OF TREATMENT MAY RESULT IN A PENALT... | |
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| Appears In: | Fillable Physicians Initial Report |
