Self-Insured Provider's Initial Report (PIR) Order Form

Only medical providers and self-insurers should use this form to order the Provider's Initial Report (PIR) for self-insured claims. You will need to check periodically for updates to the form.

You now have 2 options for ordering PIRs. You may order: (choose one)

• The paper forms as usual
  OR
• Microsoft Word® (a fillable Word file will be sent electronically.)

Note: Send the completed PIR to the self-insured employer or their representative since they manage their own claims.

Order Self-Insured PIR form

Order Provider's Initial Report (PIR) form
* Enter your request in the spaces below.	indicates required field
Word® document (fill, save, print) Paper forms as usual.
Business information
*  Business name:
*  Contact name:
*  Email address:
*  Contact phone:	-- Ext:
Mail forms to:
*  Provider's Initial Report (PIR) (F207-028-000)	(number of forms needed)
*  Mailing address:
Mailing address (cont.):
*  City, State, and Zip:	AA AE AK AL AP AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY
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