Case Transfer Card
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Case Transfer Card Form. This is a Washington form and can be use in Claims Workers Comp.
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Tags: Case Transfer Card, F245-037-000, Washington Workers Comp, Claims
DEPARTMENT OF LABOR AND INDUSTRIES
CLAIMS SECTION
PO BOX 44291
OLYMPIA WA 98504-4291
Note: Please fold in thirds using
mark along the left edge so the
address will show in a window
envelope.
If you have changed attending health care providers, you must notify and obtain
authorization from your claims manager. We are sending you this card to request a
change of attending providers. Please fill out and return this card as soon as
possible to ensure your medical services are not interrupted.
To:
Department of Labor and Industries
Claim No.
Date I changed health care providers
Please transfer my medical case
Name of provider
From:
Provider ID# / NPI#
Name of provider
To:
Address of new provider
City
State
ZIP
State
ZIP
Reason for transfer
Today’s date
Claimant’s name
Address
City
Claimant’s signature
F245-037-000 case transfer card – English 04-2008
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