Free F242-243-000 notice of occupational disease or infection - Washington

Department of Labor and Industries Claims Section PO Box 44291 Olympia WA 98504-4291

NOTICE OF OCCUPATIONAL DISEASE OR INFECTION

Medical Provider: If you examined this worker and diagnosed him/her with an occupational disease or infection: 1.) Inform the worker of their right to file an occupational disease claim. If the worker requests, complete a Report of Industrial Insurance or Occupational Disease form and follow its mailing instructions. If a Report of Industrial Insurance or Occupational Disease form is not completed by you and the worker: 1.) Inform the worker that he or she must file a claim within two years from the date this form is signed and a copy is provided to him or her. 2.) Complete and sign this form. 3.) Provide a copy of this form to the worker. 4.) Mail the original of this form to the address above.
Note to medical provider: Please have the worker help you complete this section of the form
Worker's name Date of birth Current home address Mailing address if different Sex Phone number Worker's occupation City City State State ZIP ZIP Social Security number (ID only)

Business name of employer where most recent injurious exposure or activity occurred Employer's address Length of employment with this employer? Name of previous employers From: (mm/yy) To: (mm/yy) City

Phone number State Date of last injurious exposure or activity From: (mm/yy) To: (mm/yy) ZIP

Describe the exposure or activity which appears to have caused the occupational disease or infection

Medical Provider: Please complete the section below in full
Medical provider's name Address Provisional diagnosis ( Use both standard description and ICDA code) Type of exposure which caused the occupational disease/injury (Such as noise, specific chemicals, toxic substances, specific job-related activities, bacterial or viral infections) City Date of first treatment (mm/yy) Phone number State ZIP Provider account/NPI number

I certify that I have examined this worker and have determined that he or she has a disease or infection (diagnosed above) caused by his or her occupation. I have advised the worker of his/ her right to file a claim for workers' compensation benefits. I also explained that claims must be filed within two years from the date this form is signed and provided to the worker.
Licensed physician must sign Today's date (mm/dd/yy) Signature

F242-243-000 Notice of Occupational Disease or Infection 09-2007

Original ­ L&I

Copy ­ Worker