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