| Location: | Home  Fillable Activity Prescription Form Fillable Activity Prescription Form Properties |
| Location: | Home Fillable Activity Prescription Form Fillable Activity Prescription Form Properties |
 |
| Fillable Activity Prescription Form | |
| Handle: | Version-73864 |
| Owner: | Conti, Linda (User-3767, 10557:EVERETT)DS |
| Friday, August 19, 2016 11:16:07 AM PDT | |
| Wednesday, October 12, 2016 01:10:21 PM PDT | |
| Modified By: | |
| - F242-385-000 Insurer Activity Prescription Form (APF) 07-2009 APF State Fund Claims: Dept. - ?Yes ?No Modified duty available? ?Yes ?No Date of contact: ______/______/______ Name of contact:________________________ Notes: Note to Claim Manager: New diagnosis:________________________ Opioids prescribed for: ? Acute pain or ? Chronic pain Required: 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 ... | |
| 1 | |
| Appears In: | Fillable Activity Prescription Form |
