Insurer Activity Prescription Form

Completing the Insurer Activity Prescription Form

How do I complete the APF?

Health care providers must complete all portions of the form that apply to this worker's status. Writing "See chart notes" on the form is NOT acceptable. Chart notes are essential and must still be submitted for every visit billed.

What is required on the form to ensure payment?

SectionRequired information
General InfoAll fields must be completed. Patient ID (peel and stick) labels may be used, as long as all the requested information is provided. ICD-9 codes or written diagnoses may be used.
Released for work? One section must be completed to indicate work status. Dates or a time span must be included.
Key Objective Finding(s)If the worker is not returned to full duty, objective medical findings (OMF) must be documented. OMFs are verifiable on exam. Examples are:
  • X-rays.
  • Swelling.
  • Muscle atrophy.
  • Decreased ROM.
They do not include subjective complaints such as pain, tenderness or fatigue.
Estimate of what the worker can do

Capacities are applicable 24 hours a day, not just at work. Restrictions must be provided even when the patient is off work. Including current restrictions may enable employers to identify appropriate light/modified duty jobs. The Key Objective Findings must support your restrictions.

  • If the patient cannot perform any work, note which activities are "Never" allowed in the appropriate column.
    OR
  • Use the "Other Restrictions/Instructions:" box to explain, e.g. "Patient hospitalized" or "patient cannot ambulate" etc.

The Health Care Provider can document the estimate of what the worker can do by either:

  1. Completing at least one box in the "Required: estimate what the worker can do" section
    OR
  2. Writing that information in the "Other Restrictions/Instructions:" box if the limitation type is not listed, e.g. "Patient vision completely obstructed by bilateral eye patches", etc.
  • "Employer Notified..." is not required but, is an advisable best practice. It may be billed as a separate service, with proper supporting documentation, in addition to this form.
  • "Note to Claim Manager:" is not required. It is intended to assist you in drawing the claim manager's attention to an issue, i.e. "right shoulder strain should be included on claim." To ensure clear communication complete sections for "New diagnosis" and "Opioids prescribed for acute or chronic pain."
PlansYour plan must be documented. Please include your assessment of progress, any rehabilitation, and if treatment is continuing or concluded. This information is critical for claim management decisions.
Sign

Your signature and date must be provided.

Note:

About impairment ratings
We encourage you, the qualified attending health-care provider, to rate your patient's permanent impairment. If this claim is ready to close, please examine the worker and send a rating report.

Qualified attending health-care providers include doctors currently licensed in medicine and surgery (including osteopathic and podiatric) or dentistry, and chiropractors who are department-approved examiners.

Clinical scenarios and form samples

Note: If a worker has more than 1 injured body part in the "Note to Claim Manager", indicate how you have marked the "Doctor's Estimate of Physical Capacities." For example: 1=left knee, 2=left shoulder.

Sample 1: Worker requires temporary, modified duty while recovering from injury. Complete all sections. See sample 1 (67 KB PDF).

Sample 2: Worker is off work due to an industrial injury or occupational disease. Complete all sections. See sample 2 (68 KB PDF).


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

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