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Insurer Activity Prescription Form

Authorization requirements

Health care providers are only authorized to submit APFs along with a report of accident (ROA) or Providers Initial Report (PIR). The ROA/PIR must show the worker has physical work-related restrictions that must be accommodated for light duty work.

If the insurer requires additional APFs, they will send a request letter with a blank APF.

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 when 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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