Consultation Referral
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Consultation Referral Form. This is a Washington form and can be use in Claims Workers Comp.
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Tags: Consultation Referral, F245-299-000, Washington Workers Comp, Claims
Department of Labor and Industries
Claims Section
PO Box 44319
Olympia WA 98504-4291
To: (Consultant’s name)
CONSULTATION REFERRAL
Patient history summary for:
Name:
Claim #:
DOI:
Nature of work:
Transfer
Consultation
Date of first treatment:
Employer:
History of injury and/or attach a copy of accident report:
Accepted condition: (diagnosis)
X-ray findings:
Time loss:
Previous attending physicians for this injury:
Care provided to date:
Progress to date: (Include change in subjective & objective findings compared to onset of accepted condition.)
Requested by: (attending doctor)
Date:
Letter
Phone
Reason for consultation:
Clinical issues
120 day consultation
Closing
An appointment has been made with:
Other
Date:
**Claimant**
To be completed by Attending doctor An appointment has been made with:
Time:
Attending doctor, tear & send lower portion to claimant
Phone:
Date:
Time:
**I understand that failure to keep this appointment may
jeopartize further benefits on my claim.
White – L&I Headquarters
Canary – Consultant prior to appointment date
Pink – Attending Doctor
F245-299-000 consultation referral 6-02
(Claimant’s Signature)
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