Beginning November 1, 2007, the Department of Labor & Industries has mandated the use of the Activities Prescription Form for both State Fund and Self-Insured employers.
While replacing four State Fund forms, this form only replaces the Medical Progress Report that the Washington Self-Insurers Association had developed a number of year ago.
The Department will provide you with a stack of APF's, or you can request one by email that will allow you to fill out the name of your company (as well as other fields). However, we've taken the liberty of posting that form here.
The
Activities Prescription Form (APF) comes in a "pdf" format
which requires Adobe's Acrobat
Reader in order to view and search through the document.
If you don't already have it, you can download it here. It's free from Adobe.
Here's the memo that Self-Insurance Program Manager Jean Vanek sent out regarding the form on October 2, 2007:
Starting November 1, 2007, self-insured employers and their claim representatives will have a new tool to help manage claims. The Activity Prescription Form (APF) consolidates comprehensive medical information into a single form. The APF should reduce the number of requests you have to make regarding each claimant by including information regarding
• Work status,
• Work-related physical restrictions,
• Verification of time-loss, if appropriate, and
• Treatment plans.
Under separate cover, doctors have been instructed that they can complete an initial APF for every claim involving physical restrictions. Claim managers may then request subsequent APFs at critical junctures throughout the claim.
For self-insurers, the APF is available in two versions:
1. A generic hardcopy format. For information on how to order copies, please go to http://www.lni.wa.gov/ClaimsIns/Providers/Manage/RTW/ActivityRX/obtain.asp
2. An electronic, fillable format. The form is in Adobe .pdf format, and each employer or TPA can add their own return address, fax numbers, and/or company specific information and instructions. Other than these three customizable spaces, the form is identical to the hardcopy version. To request a copy of the electronic version, please send an e-mail to SIAPFmbx@Lni.wa.gov.
If you would like to review more information regarding the APF, including billing codes, please see Provider Bulletin 07-08 at http://www.lni.wa.gov/ClaimsIns/Files/Providers/ProvBulletins/PbFiles/PB0708.pdf.
Additional information about the form is also available at
http://www.lni.wa.gov/ClaimsIns/Providers/Manage/RTW/ActivityRx/default.asp.
IMPORTANT CLARIFICATION FOR SELF-INSURED VOC PROVIDERS
Thank you to everyone who noted that the Department was not giving the same, consistent message regarding who may request an APF. Self-Insurers and our vocational providers CAN request the medical providers to fill out the APF. The confusion stemmed from the Department using the term "employers" (i.e. - State Fund employers) and "insurers" interchangeably. At WSIA's request, they have updated their website to clarify that the prohibition only applies to State Fund employers, NOT self-insurers. Thank you for bringing that to our attention!
revised 5 February 2008
NEW!
DEPARTMENT RESPONSE TO PROLIANCE REGARDING THE APF
Proliance, a provider under the Department's Ortho-Neuro pilot, had sent a letter out to self-insured employers and TPA's indicating that they were going to charge the same, inflated rate to self-insured employers that were not in the pilot project, and at their discretion (only ONE self-insured employer of 385 is signed up for the pilot project). The Department has informed Proliance that they must follow the fee schedule and rules for non-pilot project self-insured employers.
READ the Department's Memo to the Self-Insured community
regarding Proliance.
READ the Department's outline of responsibility given
to Proliance and other providers.
11 April 2008
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