Filling out the Report of Accident

Report of Industrial Injury or Occupational Disease

To speed up the claim process, make sure the accident report is:

greencheckmark Understood by the worker.

greencheckmark Filled out completely, leaving areas blank may delay processing of the claim and your bills. If the condition is a disease, enter "N/A" for "not applicable" in both of the following boxes:

  • Date of injury.
  • Time of injury.

greencheckmark As specific as possible.

  • Include a complete diagnosis and appropriate Common Diagnostic Codes (ICD codes). Clarify a specific body site and the definition of the injury.
  • If your patient is unable to perform any work due to the injury or disease, estimate how much time the injured worker will lose due to the injury.

greencheckmark Signed by both you and your patient.

greencheckmark Submitted promptly with copies of the:

  • History and physical,
  • Emergency room evaluation, or
  • Your office notes.

Consider contacting the employer

  • If you have questions or concerns about the relationship between an exposure and the illness being treated.
  • To request material safety data sheets (MSDS).
  • To walk through the job site.

Treating L&I-insured injured workers?

  • You don't need to mail the ROA to the employer. You may ask the worker to deliver a copy to the employer. We'll notify the employer about the claim when we receive the ROA from you.
  • If you fax the ROA, don’t mail the original to L&I, unless we request it. Save the original in your files for legal purposes.

Treating injured workers whose employers are self-insured?

  • If you treat injured workers at a self-insured employer’s on-site medical facility, find out about reporting and record-keeping requirements: Contact L&I's Self-Insurance Section at 360-902-6842.

Continue on to file a Report of Accident

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