Activity Prescription Form

Ordering the Activity Prescription Form

The insurer will supply healthcare providers with an APF to complete with their request. Self-insurers or their third party administrators may send customized APFs.

Healthcare providers: Keep a supply of APFs in your office for submitting with a report of accident or Physician Initial Report (PIR) when there are physical restrictions. There are several ways to obtain APFs:

  • Print one now
  • Use fillable form
  • Order online
    You may add the APF to your electronic medical records system. All fields on the completed copy submitted to the department must appear in the same location as they appear on the department form. Contact Angelique Alberg, for more information.

Healthcare providers: Fill out the order form below and L&I will mail the APFs to you.

Activity Prescription Order Form
I want to order copies (copies are singles sheets, not pads).
: 000-000-0000
Please send them to:
: 00000-0000

Order by fax

Healthcare providers: Fax your order to the L&I Warehouse at 360‑902‑4525. Include in your faxed request the following information:

  • "Activity Prescription Form - F242-385-000".
  • Your name.
  • Your company name.
  • Mailing address.
  • Telephone number.
  • Quantity (copies are singles sheets, not pads).

Call the Provider Hotline 1-800-848-0811 for questions about the APF.

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