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Activity Prescription Form

What is the Activity Prescription Form (APF)?

Providers complete APFs to communicate the worker’s:

  • Ability to work
  • Functional capacities
  • Physical restrictions
  • Treatment plan

APFs are also used to help:

  • Employers develop modified work plans while their worker is recovering.
  • L&I claim managers understand the worker’s ongoing treatment and medical progress, and to authorize time-loss benefits.
  • Vocational rehabilitation counselors (VRCs) build appropriate return to work plans.
  • Workers understand what they can do. It can be used as a motivator in their healing process.

Who may ask the provider to complete an APF?

  • The Claim Manager
  • The worker’s Vocational Rehabilitation Counselor (VRC)
    • A VRC may request an APF to clarify or update information about the worker’s physical capacity or condition.
  • Self-Insured Employers (SIEs) or their 3rd party administrators
    • May request, but the APF is paid for by the employer

NOTE: L&I does not pay for APFs completed at the request of:

  • Attorneys, or
  • Employers covered by L&I

Record keeping

If there are multiple claims for a worker, put all claim numbers on the:

    • APFs
    • Bills
    • Chart notes
    • Reports
  • Give a copy of the APF to the worker, so they can show it to their employer
  • Keep APFs, chart notes, reports and other information in your files for a minimum of 5 years for audit purposes

Other forms employers may request:

Employers MAY contact their worker’s attending provider to clarify what work he or she may do safely during recovery by asking him or her to:

You can remind employers to review the completed APFs that are a part of the worker's claim file in the Claim & Account Center.Secure

Questions?

For questions about the APF - call the Provider Hotline 1-800-848-0811.

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