Free F245-037-000 case transfer card for internet - English - Washington


File Size: 150.9 kB
Pages: 1
Date: April 28, 2008
File Format: PDF
State: Washington
Category: Workers Compensation
Author: Forms Management
Word Count: 144 Words, 867 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.lni.wa.gov/Forms/pdf/245037a0.pdf

Download F245-037-000 case transfer card for internet - English ( 150.9 kB)


Preview F245-037-000 case transfer card for internet - English
DEPARTMENT OF LABOR AND INDUSTRIES CLAIMS SECTION PO BOX 44291 OLYMPIA WA 98504-4291
Note: Please fold in thirds using mark along the left edge so the address will show in a window envelope. If you have changed attending health care providers, you must notify and obtain authorization from your claims manager. We are sending you this card to request a change of attending providers. Please fill out and return this card as soon as possible to ensure your medical services are not interrupted. To: Department of Labor and Industries Claim No. Date I changed health care providers

Please transfer my medical case
Name of provider

From:
Name of provider

To: Address of new provider Reason for transfer Today's date Claimant's name Address City City

Provider ID# / NPI# State ZIP

State

ZIP

Claimant's signature
F245-037-000 case transfer card ­ English 04-2008