Fill and Sign the Pre Job Modification Accommodation Assistant Application Washington Form

Department of Labor and Industries Claims PO Box 44291 Olympia WA 98504-4291 Fax completed application directly to claim file at 360-902-4567. Pre-Job Accommodation Assistance Application Worker Name       Job Goal       Claim Number(s)       Submit this application if all of the following criteria are met:  You have a state fund claim.  Your claim is open or is a statutory pension.  The equipment accommodates restrictions imposed by the accepted condition(s) on your claim.  The attending provider (AP) has verified the requested item(s) are medically necessary for the accepted condition(s).  No employee-employer relationship exists.  Request does not exceed benefit maximum of $5,000 (combined with prior approvals/job modification benefit).  Items being requested are not above and beyond necessity or for convenience. and  The items are needed for: (check which option applies) Retraining Plan OR Job Goal  Participate in a retraining plan, and  The retraining site is not able to provide requested accommodations.  Perform essential functions of a job consistent with recommendation of a vocational assessment or (nearly) completed plan, and  The labor market is positive with modifications and does not already supply the requested item(s). Required Attachments: 1. AP’s statement of medical necessity for each requested item. 2. Consult report and/or 1 page narrative report. 3. Vendor bid (include a 2 nd bid if a single item including tax, shipping, and delivery is over $2,500). 4. Signed Pre-Job Accommodation Ownership Agreement (2 nd page of this form). List specific equipment, training, tools requested:       Itemization of Costs: Vendor Information (one per application) Equipment/Tools/Other:       Vendor Name       L&I Provider Number       Assembly, Installation, & Delivery:       Address       Phone Number       Tax:       City       State       Zip Code       Total: $0.00 An L&I Provider Number is required for payment. Contact Provider Credentialing 360-902-5140 for more information. Submit your bill on the Statement for Retraining and Job Modification Services (F245-030-000) . Use procedure code 0385R. Include your invoice and a copy of this approved application form. Requested By       Company Name       L&I Provider Number (if present)       Phone Number       Fax Number       Date       Requestor’s Signature L&I Use Only Approved Approved with Modifications:       Disapproved Total Amount Approved       Date       Signature Authority       F245-350-000 Pre-Job Accommodation Assistance Application 11-2015 Index: JMOD Pre-Job Accommodation Ownership Agreement Worker Name:       Claim Number(s):       Return-to-Work Job 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 Labor & Industries (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 will make every effort to keep these items safe and free from damage.  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, if I select Option 2, 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 equipment to the nearest L&I service location. I understand the agreement as shown above and I am willing to comply with the terms.       Worker Signature Date       Witness Signature Date Inventory: Item Brand/Manufacturer                                                                         F245-350-000 Pre-Job Accommodation Assistance Application 11-2015 Index: JMOD