Department of Labor and Industries Claims PO Box 44291 Olympia WA 98504-4291 Fax completed application directly to claim file at 360-902-4567. Worker Name Job Goal Pre-Job Accommodation Assistance Application Claim Number(s) Submit this application if all of the following criteria are met: You have a state fund claim. Your claim is open or is a statutory pension. The equipment accommodates restrictions imposed by the accepted condition(s) on your claim. The attending provider (AP) has verified the requested item(s) are medically necessary for the accepted condition(s). No employee-employer relationship exists. Request does not exceed benefit maximum of $5,000 (combined with prior approvals/job modification benefit). Items being requested are not above and beyond necessity or for convenience. and The items are needed for: (check which option applies) Retraining Plan Participate in a retraining plan, and The retraining site is not able to provide requested accommodations. OR Job Goal Perform essential functions of a job consistent with recommendation of a vocational assessment or (nearly) completed plan, and The labor market is positive with modifications and does not already supply the requested item(s). Required Attachments: 1. AP's statement of medical necessity for each requested item. 2. Consult report and/or 1 page narrative report. 3. Vendor bid (include a 2nd bid if a single item including tax, shipping, and delivery is over $2,500). 4. Signed Pre-Job Accommodation Ownership Agreement (2nd page of this form). List specific equipment, training, tools requested: Itemization of Costs: Equipment/Tools/Other: Assembly, Installation, & Delivery: Tax: Vendor Information (one per application) Vendor Name Address City State L&I Provider Number Phone Number Zip Code An L&I Provider Number is required for payment. Contact Provider Credentialing 360-902-5140 for more information. Total: $0.00 Submit your bill on the Statement for Retraining and Job Modification Services (F245-030-000). Use procedure code 0385R. Include your invoice and a copy of this approved application form. Requested By L&I Provider Number (if present) Date Phone Number Company Name Fax Number Requestor's Signature L&I Use Only Approved Approved with Modifications: Date Signature Authority American LegalNet, Inc. www.FormsWorkFlow.com Disapproved Index: JMOD Total Amount Approved F245-350-000 Pre-Job Accommodation Assistance Application 11-2015 Pre-Job Accommodation Ownership Agreement Worker Name: Return-to-Work Job Goal: Claim Number(s): Required for Return-to-Work (RTW) Goal This accommodation is related to my attending health care provider's requirements for my release to work. I will own these items upon my release to work as determined by Labor & Industries (L&I). Required for Participation in a Retraining Plan Plan Dates: This accommodation is related to my attending health care provider's requirements to participate in my retraining plan. These items remain the property of L&I during my retraining plan. Permission to use these items is based on cooperative participation in my retraining plan and may be withdrawn at any time while L&I remains the owner. I will make every effort to keep these items safe and free from damage. I will own these items upon my successful completion of the retraining plan as determined by L&I. Return Policy If I do not use these items in my RTW goal, if my retraining plan fails, if I select Option 2, or if my counselor or L&I inform me for any reason that this equipment must be returned, I will do so immediately. I will contact L&I and make arrangements to return equipment to the nearest L&I service location. I understand the agreement as shown above and I am willing to comply with the terms. Worker Signature Date Witness Signature Inventory: Item Date Brand/Manufacturer F245-350-000 Pre-Job Accommodation Assistance Application 11-2015 American LegalNet, Inc. www.FormsWorkFlow.com Index: JMOD