Activity Prescription Form to Treat Injured Workers

The Washington State Department of Labor & Industries' (L&I) web site does not properly display because JavaScript is disabled or not supported by your browser.The following links may help you navigate the L&I web site:

Topic Index.

Home.

Safety.

Find a Law (RCW) or Rule (WAC).

Help.


Activity Prescription Form to Treat Injured Workers

Completing the Insurer Activity Prescription Form

How do I complete the APF?

Health care providers must complete the form. 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?

Section	Required information
General Info	All 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 indicated 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. In addition, including current restrictions may enable employers to identify appropriate light/modified duty jobs. "Other Restrictions/Instructions:" "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."
Plans	Your 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 1-800-848-0811.