Used by a therapy provider/clinic to request authorization for outpatient occupational or physical therapy services for L&I claims.

The physical / occupational therapist uses this report to identify the clinical goals and return to work objectives of the injured worker.

For use by a therapist or vocational provider to request job modification for an injured worker before the injured workers is employed, possibly in a retraining program. This may involve tools and equipment that is purchased through L&I.