COHE Forms & Resource Links

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Activity Prescriptions Form 

 

L&I Activity Prescription Form 

The 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. Completion of this form allows COHE providers to receive enhanced fees using billing code 1073M.   

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Clinic Job Aid 

  COHE Process Job Aid (Clinic)
An efficient job aid for providers, support staff, medical records, billing and administrators as a quick glance guide describing each step of the Occupational Health Best Practices in a clinic setting.   
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 ED Job Aid 

  COHE Process Job Aid (Emergency Department)
An efficient job aid for providers, support staff, medical records, billing and administrators as a quick glance guide describing each step of the Occupational Health Best Practices in a ED setting. 
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 /uploadedImages/Program_Resources/Updated_COHE_Forms/E_WA_COHE_Forms/EmplJD_Page_1.jpg 

 

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 Vocational Rehabilitation Counselor.  

 

 Download 
 /uploadedImages/Program_Resources/Updated_COHE_Forms/E_WA_COHE_Forms/APP Applicaiton Supplement 7 1 08_Page_3.jpg    COHE Letter of Intent
This form is to be completed as a statement of interest in MDs, DOs, DCs, ARNPs, and PACs that would like to participate in COHE.  Providers from the counties of Adams, Asotin, Benton, Chelan, Columbia, Douglas, Ferry, Franklin, Garfield, Grant, Kittitas, Lincoln, Okanogan, Pend Orielle, Spokane, Stevens, Tricities, Walla Walla, Whitman and Yakima are eligible. Completed forms should be faxed to the COHE office at 866-853-0137. 


 
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 /uploadedImages/Program_Resources/Updated_COHE_Forms/E_WA_COHE_Forms/Dept of LI.JPG    Department of Labor and Industries
Official website of the Washington State Department of Labor & Industries.  Access information regarding all aspects of the Department for businesses, workers and medical providers, including locating a provider approved in the Medical Provider Network, FileFast, ordering L&I forms and completing forms online. 
 
       
       
 /uploadedImages/Program_Resources/Updated_COHE_Forms/E_WA_COHE_Forms/CAC.JPG     Claims and Accounts Center (SAW)
Secure Access Washington is a single sign-on application gateway that allows you to access multiple online government services including Claims and Accounts Center (CAC) to review injured worker claims. 

 
 

  

   
 
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