Department of Labor and Industries Claims Section PO Box 44319 Olympia WA 98504-4291
To: (Consultant's name) Name: Nature of work: History of injury and/or attach a copy of accident report: Patient history summary for: DOI:
CONSULTATION REFERRAL
Transfer Consultation Claim #: Date of first treatment:
Employer:
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) Reason for consultation:
Date:
Letter Phone Other
Clinical issues
120 day consultation
Closing
An appointment has been made with:
Date:
Time:
To be completed by Attending doctor An appointment has been made with:
**Claimant**
Phone: Date:
Attending doctor, tear & send lower portion to claimant
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 (Claimant's Signature)
F245-299-000 consultation referral 6-02