Free Consultation Referral - Washington

Department of Labor and Industries Claims Section PO Box 44319 Olympia WA 98504-4291
To: (Consultant's name) Name: Nature of work: History of injury and/or attach a copy of accident report: Patient history summary for: DOI:

CONSULTATION REFERRAL
Transfer Consultation Claim #: Date of first treatment:

Employer:

Accepted condition: (diagnosis)

X-ray findings:

Time loss: Previous attending physicians for this injury: Care provided to date:

Progress to date: (Include change in subjective & objective findings compared to onset of accepted condition.)

Requested by: (attending doctor) Reason for consultation:

Date:

Letter Phone Other

Clinical issues

120 day consultation

Closing

An appointment has been made with:

Date:

Time:

To be completed by Attending doctor An appointment has been made with:

**Claimant**
Phone: Date:

Attending doctor, tear & send lower portion to claimant

Time:

**I understand that failure to keep this appointment may jeopartize further benefits on my claim.
White ­ L&I Headquarters Canary ­ Consultant prior to appointment date Pink ­ Attending Doctor (Claimant's Signature)

F245-299-000 consultation referral 6-02