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Cómo Hacer la Mejor Elección de Tratamiento para el Dolor Crónico en la Parte Inferior de su Espalda

Hoja de información:  Revisa las opciones que un trabajador lesionado con dolor en la parte inferior de la espalda debe considerar para determinar la elección del mejor tratamiento.



Publication
F252-081-999



Alt Language(s):
Inglés
 
Crime Victims Compensation Program Initial Response and Assessment: Form II

Used by the clinical provider to request authorization to provide more than six sessions. This form must be submitted by the sixth session. (6 pages)



Form
F800-081-000


 
CVCP Opioid Progress Report Chronic, Non-Cancer Pain and Treatment Agreement.

Crime Victims Compensation Opioid Progress Report Chronic, Non-Cancer Pain and Treatment Agreement.



Form
F800-116-000


 
L&I Benefits for Workers Who Are Terminally Ill

Answers questions persons with a terminal illness may ask about benefits from L&I.



Publication
F252-094-000


 
Need a Doctor?

Information card: Provides contact information for injured workers needing assistance in finding a health-care provider who will treat their occupational injury or disease. This PDF will print out an 8.5" X 11" sheet that has 12 copies of the card. Note: Disclaimer information on Page 2 may not line up accurately in two-sided printing.



Publication
F160-006-000



Alt Language(s):
Español
 
Opioid Treatment Agreement

Use this treatment agreement when starting chronic opioid therapy. It should be renewed yearly or when there is a new prescriber.



Form
F252-095-000



Alt Language(s):
Español
 
Provider's Initial Report (PIR)

Used by medical providers when reporting initial treatment for an industrial injury or occupational disease for a self-insured claim. The paper version dated 10-2012 is still valid, as is the 01-2014 word fillable version.

Medical providers treating self-insured workers, self-insured businesses, or their third party claims administrators can access this form one of two ways:

  1. Download the Microsoft (MS) Word form and the PDF file with instructions:

           The first file is the PDF instructions.

           The second file is an Office 2003 MSWord document ending in .doc.

           The third file is an Office 2007/2010 version, ending in .docx.

2.  Order paper copies of this form by clicking the “order it” button.



Form
F207-028-000


 
Request for Survivor Counseling Benefits (English/Spanish) Solicitud para Beneficios de Apoyo para los Sobrevivientes  

Used by immediate family members of homicide victims to request mental health counseling.



Form
F800-057-909


 
Travel Reimbursement Request

Bill form for use by workers to request reimbursement for authorized travel expenses.



Form
F245-145-000



Alt Language(s):
Español
 
Crime Victims Compensation Program Initial Response and Assessment: Form I
Used by the clinical provider to get approval to see a victim for six sessions or less. If more than six sessions, please complete Form II (F800-081-000).

Form
F800-080-000


 
Making the Best Treatment Choice for Your Chronic Low-back Pain
Fact sheet: Reviews the options that an injured worker with low-back pain should consider in determining the best treatment choice.

Publication
F252-081-000


 





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