Report of Industrial Injury or Occupational Disease
Continue on to file a Report of Accident.
To speed up the claim process, make sure the accident report is:
Understood by the worker
- If your patient prefers to communicate in a language other than English, you can get an interpreter.
- Note: For Spanish-language instructions on how to fill out the ROA, you can order copies and L&I will mail them to you.
- Check the Related Resources section at the bottom of this page for additional language options. You can print them and give them to the worker.
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
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.
- Verify the Causal Relationship box in the Healthcare Provider Information section is completed.
Signed by both you and your patient
Submitted promptly with copies of the:
- History and physical,
- Emergency room evaluation, or
- Your office notes.
Contact 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?
Treating injured workers whose employers are self-insured? If you treat injured workers who work for self-insured employers- find out about reporting and billing on the Self-Insurance Providers page.
Using paper forms versus online filing through FileFast
Watch this short video on paper vs. online filing
Filing by paper can cause delays to services and benefits to your patients.
Filing your ROA online with FileFast gets you faster treatment authorization, plus other benefits:
- Get instant confirmation of receipt, saving your office time.
- Avoid delays in claims decisions by capturing critical information upfront.
- Speed the delivery of care and benefits to workers.
- Reduce delays in payment to medical providers.
- Get a $10 payment incentive for filing online — billing code 1040M.
Attend one of our free FileFast webinars for medical provider offices.
How to order the paper Report of Accident:
Use the new form as soon as it arrives. Please discard any outdated versions of the Report of Accident.
Note: Please limit your order of the paper ROA form to a 3-month supply. Our warehouse reserves the right to mail a smaller order.