E WA COHE Forms

Claim-Related Forms                                               All Downloads require Adobe Acrobat Reader 

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L&I Activity Prescription Form v4 (9/2013)                                     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 1073M (see COHE Fee Schedule). This form can also be filled out on-line in the COHE Claim Tracking System. 

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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 to a workplace injury AND the employer is not paying full wages. Providers are encouraged to have these forms available to workers.  
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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 to a workplace injury AND the employer is not paying full wages. Providers are encouraged to have these forms available to workers. 
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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.  

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COHE Letter of Intent
This form to be completed as a statement of interest in MDs, DOs, DCs, ARNPs, and PA-Cs participating in COHE.  Providers from the counties of Adams, Asotin, Benton, Chelan, Columbia, Douglas, Ferry, Franklin, Garfield, Grant, Kittitas, Lincoln, Okanogan, Pend Orielle, Spokane, Stevens, Walla Walla, Whitman and Yakima are eligible. Completed forms should be faxed to the COHE office. 

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COHE Participating Employer Application                                 Employers that 'participate' in the COHE can view specific information about their employee'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. 

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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. 

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