Activity Prescription Form

Authorization requirements

Health care providers should submit an APF with a report of accident (ROA) or Providers Initial Report (PIR) when there are work related physical restrictions. After the initial visit, please complete an APF when documenting a change in your patient's medical status or capacities.

A provider may submit up to 6 APFs per worker within the first 60 days of the initial visit date and then up to 4 times per 60 days thereafter.

Which situations do or do not require an APF with the ROA/PIR and chart notes?
If the worker:Submit APF?
Is released to work without restrictionsNo
Has a simple injury without restrictions. For example:
  • Simple eye injuries.
  • Lacerations without tendon or nerve involvement.
No
Has a simple injury with restrictions that do not require light/modified duty. For example:
  • "Keep the wound dry by using a waterproof glove."
  • "Elevate the leg for 5 minutes every hour for 3 days."
No
Has work-related physical restrictions that must be accommodated for light-duty work.Yes

Is an office visit necessary if the insurer asks you to complete an APF?
If you: Office visit? Then:
Examined the worker within the last 30 daysNoUse information from your last visit as the basis for your opinion.
Are uncertain about the worker's current need for treatment or work restrictions
or
It has been more than 30 days since you examined this worker.
YesSchedule an appointment with the worker as soon as possible.
Are no longer treating this worker.NoIndicate the last known status and return the form as soon as possible.
Concluded treatment.NoComplete the portions of the form that apply to the worker's medical status when you conclude treatment, including the "Plans" section.


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

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