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• Ordering forms
• Completing
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• Billing
• Recordkeeping

Ordering the Insurer 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 and vocational providers: Keep a supply of APFs in your office for submitting with a report of accident or Physician Intial Report (PRI) when there are physical restrictions. There are several ways to obtain APFs:

• Print one now
• Electronic form, contact Joanne McDaniel
• Order online

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

Insurer Activity Prescription Order Form
I want to order copies (copies are singles sheets, not pads).
Name:
Phone:	000-000-0000
Please send them to:
Company:
Attention:
Mailing Address:
City:
State:
Zip:	00000-0000

Order by fax

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

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

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