Fill and Sign the Consultation Referral Washington Form

                                                                                                                                                  Letter Phone             Letter Phone                                          ( ) Department of Labor and Industries Claims Section CONSULTATION REFERRAL PO Box 44291 Olympia WA 98504-4291 To: (Consultant's name) Patient history summary for: Transfer Claim #- Consultation Name: DOI: Date of first treatment: Nature of work: Employer: History of injury and/or attach a copy of accident report: 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.) Reason for consultation: An appointment has been made with: Date : Time: ** I understand that failure to keep this appointment may jeopardize further benefits on my claim. (Claimant's Signature) Requested by: (attending doctor) Date Verification authorized by: (claim adjudicator) Date To be completed by Attending Doctor - "Claimant" Attending doctor, tear & send lower portion to claimant An appointment has been made with: Phone Date Time: I understand that failure to keep this appointment mayjeopardize further benefits on my claim.(Claimant's Signature) F245-299-000 (PDF) consultation referral 2-99 White - L&I HeadquartersCanary - Consultant pnor to appointment datePink - Attending Doctor