Free F245-350-000 prejob accommodation assistance application - Washington

Mail completed application form to: Department of Labor & Industries Claims Section PO Box 44291 Olympia WA 98504-4291

PRE-JOB ACCOMMODATION ASSISTANCE APPLICATION

One vendor per application form
Injured worker's name Vocational counselor/pre-job accommodation consultant Firm's name Address City
Proposed job title RESTRICTIONS

Date of injury

Claim number

Accepted diagnosis Provider number Phone number Fax number State ZIP+4

For:

Retraining site

Job/Return-to-Work goal

DESCRIPTION OF PRE-JOB ACCOMMODATION

ITEMIZATION OF COSTS:
Equipment Tools Other Assembly, installation & delivery Tax Total Vendor name Address City Date State Vocational counselor or consultant signature

REQUIRED DOCUMENTATION Pre-job accommodation narrative or consultation report AND Ownership agreement AND Attending Doctor's Statement of Medical Necessity AND Bids (2 bids if single item over $2,500)

Labor and Industries (L&I) provider number required for payment. If equipment vendor does not have a L&I provider number ­ Call: Provider Accounts (360) 902-5140 For payment, submit bill on pink "Statement for Retraining and Job Modification Services" form (F245-030-000). Attach copy of approved application.

$

0.00

Provider number

ZIP+4

Phone number

For Dept Use Only Date

Approve

Authorization code (0385R) entered on AUTH Signature authority

Authorization amount entered on CLOG

Disapprove

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Ownership Agreement for Tools and Equipment Purchased as a Pre-Job Accommodation
Worker Return-to-work Goal Required for Return-to-Work (RTW) Goal · This accommodation is related to my attending health care provider's requirements for my release to work. · I will own these items upon my release to work as determined by L&I. Required for Participation in a Retraining Plan Plan Dates: ______________________________ · This accommodation is related to my attending health care provider's requirements to participate in my retraining plan. · These items remain the property of L&I during my retraining plan. · Permission to use these items is based on cooperative participation in my retraining plan and may be withdrawn at any time while L&I remains the owner. · I am fully responsible for the custody of the listed items and agree to maintain these items and keep them secure from damage, loss, or theft. · I will own these items upon my successful completion of the retraining plan as determined by L&I. Return Policy: If I do not use these items in my RTW goal, if my retraining plan fails, or if my counselor or L&I inform me for any reason that this equipment must be returned, I will do so immediately. I will contact L&I and make arrangements to return the equipment to the nearest service location. I understand the agreement as shown above and I am willing to comply with the terms. Worker Signature Witness Signature Inventory
Item Brand/Manufacturer Model # Date Date

Claim #:

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INSTRUCTIONS FOR COMPLETING THE PRE-JOB ACCOMMODATION ASSISTANCE APPLICATION FORM (F245-350-000) This benefit is only available to a worker with a state fund claim or a claim against a defaulting self-insured employer. NOTE: SUBMIT A SEPARATE APPLICATION FOR EACH VENDOR.

1) DATE OF INJURY: Record the date of injury. 2) CLAIM NUMBER: For the injured worker on whose behalf the application is being submitted. 3) INJURED WORKER'S NAME: Injured worker's full name. 4) ACCEPTED DIAGNOSIS: Record the accepted industrial condition(s). 5) VOCATIONAL COUNSELOR/ CONSULTANT: Record the name of the individual submitting the application (must be vocational counselor, pre-job accommodation consultant, or employer that has been trained in completing the applications.) May not be submitted by the worker. a) FIRM NAME: Record the firm that the vocational counselor/consultant represents. b) PROVIDER NO.: Record the vocational counselor/consultant's provider number. c) ADDRESS: Record the vocational counselor/consultant's address, phone, and fax number. 6) PROPOSED JOB TITLE: Record the actual or anticipated job title for which the application is being submitted. 7) PURPOSE OF ACCOMMODATION: Specify if the accommodation is needed for the retraining site or for the RTW goal. 8) DESCRIPTION OF RESTRICTIONS: List the restrictions or limitations in physical capacities that relate to the requested accommodation. 9) DESCRIPTION OF PRE-JOB ACCOMMODATION: Briefly list the equipment being requested and the reason for the request. 10) ITEMIZATION OF COSTS: a) EQUIPMENT: Record the cost of equipment being requested. b) TOOLS: Record the cost of any tools being requested. c) OTHER: Record the cost of non-equipment, non-tool items, such as training time. d) ASSEMBLY: Record the cost of assembly, installation and delivery. e) TOTAL: Record total cost of accommodation requested for this vendor. 11) REQUIRED DOCUMENTATION a) REPORT: If the report has been previously submitted, please indicate that it is "on file". b) BIDS: Submit two bids for any single item over $2,500.00. The price includes any tax, shipping, delivery, and training charges. If the item is only available from one vendor, please specify that it is a sole source item. c) OWNERSHIP AGREEMENT: Submit completed form F245-350-000, page 2. d) ATTENDING DOCTOR'S STATEMENT OF MEDICAL NECESSITY: Include verification from the attending physician that the accommodations are medically necessary due to the effects of the accepted industrial condition. 12) VENDOR: Enter the vendor's name, address, phone and provider number. Vendors must have a provider number in order to be reimbursed.

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Index: JMOD