The Washington Transfer of Attending Provider Form for Self Insured Workers is a form used when a worker in Washington State is transferring from one attending provider to another. It is used to ensure that the worker’s benefits continue to be provided by their self-insured employer in accordance with applicable state laws. This form is typically used by employers when they are providing coverage for their employees under a self-insured plan. There are two types of Washington Transfer of Attending Provider Form for Self Insured Workers: a master transfer form and a transfer addendum. The master transfer form is used to transfer the entire medical record and the transfer addendum is used to transfer only portions of the medical record. Both forms must be completed and signed by both the transferring and receiving providers, the employer, and the employee before the transfer can be made.
Washington Transfer of Attending Provider Form for Self Insured Workers
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How to fill out Washington Transfer Of Attending Provider Form For Self Insured Workers?
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FAQ
If you're completely unable to work, time-loss benefits are based on your average monthly gross income at the time of your injury, including wages, health benefits, bonuses, and tips. You'll receive 60% to 75% of that income, depending on your marital status and number of dependents.
File a claim online with FileFast (24-hours per day). Workers can also file by phone at 1-877-561-FILE (3453) Monday ? Friday, 8 a.m. ? 5 p.m.
Use this form to communicate expectations of the patient to be physically active during recovery, work status, activity restrictions, and treatment plans. ? This form will also certify time-loss compensation, if appropriate.
Online via our FileFast tool. By phone: 1-877-561-FILE (3453) At your doctor's office (if you complete the Report of Accident at your doctor's office, the doctor files the form for you)