| | L&I Activity Prescription Form v4 (7/2009)
This APF is to be completed by the COHE provider on initial and follow-up visit when the injured worker has not returned to full duty. This form now replaces 5 previous L&I forms (see APF Completeness Guidelines). Completion of this form allows COHE providers to receive enhanced fees using billing code 1069M (see COHE Fee Schedule). This form is also fillable on-line in the COHE Claim Tracking System. | Download |
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| | COHE Provider-Employer Communication Form
Standardized form used by COHE Providers to document outcome of initial communication with injured worker's employer (representative) and/or labor union. This revised version includes the new billing codes for phone calls by physicians and non-physicians consistent with this form. | Download |
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 | | COHE 4-Week Assessment/Impediments Form
Standardized form used by COHE Providers to communicate probable factors serving as impediments to return-to-work to COHE Health Services Coordinators - as a 4-week assessment. This version includes recent changes to the fee codes to this Pilot Project. | Download |
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| | Worker Verification Form (English)
L&I Form to be completed by worker as a request for time-loss compensation when a worker is unable to work due toa workplace injury AND the employer is not paying full wages. Providers are encouraged to have these forms available to workers. | Download |
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 | | Worker Verification Form (Spanish)
L&I Form to be completed by worker as a request for time-loss compensation when a worker is unable to work due toa workplace injury AND the employer is not paying full wages. Providers are encouraged to have these forms available to workers. | Download |
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 | | Employer Job Description Form
L&I Form to be completed by employer of record to describe tasks and physical demands for restricted/modified duty jobs to facilitate return-to-work. Provider completes second page when presented by employer, employer representative, Claim Manager, or Voc Rehab Counselor. | Download |
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Application Forms All Downloads require Adobe Acrobat Reader |
 | | COHE Provider Application Kit
This set of forms is required for application to participate in the COHE project by MDs, DOs, DCs, ARNPs, and PA-Cs. Providers from the counties of Adams, Asotin, Chelan, Columbia, Douglas, Ferry, Garfield, Grant, Lincoln, Okanogan, Pend Orielle, Spokane, Stevens, Walla Walla, Whitman and Yakima are eligible. This is a SUPPLEMENT to existing L&I Provider Agreement. Completed forms should be faxed to the COHE office. | Download |
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| | COHE Mentor Physician Application
Physicians desiring to serve as a Mentor to other providers in the COHE project can apply by completing this form and faxing to the COHE office. Minimum criteria must be met to consider application. Final decision for acceptance is made by Dept. of L&I. | Download |
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 | | COHE Participating Employer Application
Employers that 'participate' in the COHE can view specific information about their emploee's claim and work status, if it is being managed by a COHE Provider. The COHE Occupational Medicine Information Tracking System (ATHENA) is a secure part of this website, accessible only by a secure username and password (assigned by COHE staff). Complete and fax this application to the COHE office. New participating employers will be oriented to the web application and other resources available through the COHE office. | Download |
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 | | COHE Participating Labor Union Application
Labor unions that 'participate' in the COHE can view specific information about their injured member's claim and work status, if it is being managed by a COHE Provider. Through the COHE Occupational Medicine Information Tracking System (ATHENA) advocates for injured workers can communicate with physicians and the COHE Health Services Coordinators in a timely fashion to exchange information regarding work status and return-to-work options - on behalf of that worker. Complete and fax this application to the COHE office. New participating labor unions will be oriented to the web application and other resources available through the COHE office. | Download |
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