| Activity Prescription Form to Treat Injured Workers |  | |
Authorization requirements
Health care providers are only authorized to submit APFs along with a report of accident (ROA) or Physician Intial Report (PRI). The ROA 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 and chart notes? | |
| If the worker: | Submit APF? |
| Is released to work without restrictions | No |
Has a simple injury without restrictions. For example:
| No |
Has a simple injury with restrictions that do not require light/modified duty. For example:
| 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 days | No | Use 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. | Yes | Schedule an appointment with the worker as soon as possible. |
| Are no longer treating this worker. | No | Indicate the last known status and return the form as soon as possible. |
| Concluded treatment. | No | Complete 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 1-800-848-0811.
