Activity Prescription Form - Washington State Department Of Labor
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1
2State Fund Claim:
Activity Prescription Form (APF)
Department of Labor and Industries PO
Billing Code: 1073M (Guidance on back)
Box 44291 Olympia WA 98504-4291
Fax to claim file: 360-902-4567
Reminder: Send chart notes and reports to L&I or SIE/TPA as
Self-Insured Claims:
Contact the Self Insured
required. Complete this form only when there are changes in
Employer (SIE)/Third Party Administrator (TPA)
medical status or capacities, or change in release for work status.
For a list of SIE/TPAs, go to
Worker’s Name:
Patient ID:
Visit Date:
Claim Number:
Healthcare Provider’s Name
:
Date of Injury:
Diagnosis:
(please print)
Worker is released to the job of injury (JOI) without restrictions (related to the work injury) as of (date): ____/____/____
(
If selected, skip to “Plans” section below)
Required:
Measurable Objective Finding(s)
Worker may perform modified duty, if available, from (date):
(e.g., positive x-ray, swelling, muscle atrophy,
______/_______/_______ to* _______/_______/______
(*estimated date)
decreased range of motion)
If released to modified duty, may work more than normal schedule
Worker may work limited hours:
hours/day from (date):
______
______/_______/_______ to* _______/_______/______
(*estimated date)
Worker is working modified duty or limited hours
Worker not released to any work from (date):
to*
____/____/____
__/____/____
(*estimated date)
Poor prognosis for return to work at the job of injury at any date
How long do the worker’s current capacities apply (estimate)?
Other Restrictions / Instructions:
1-10 days
11-20 days
21-30 days
30+ days
permanent
Capacities apply all day, every day of the week, at home as well as at work.
Constant
Seldom
Occasional
Frequent
Worker can:
(Related to work injury)
67-100%
Never
1-10%
11-33%
34-66%
(Not
A blank space = Not restricted
0-1 hour
1-3 hours
3-6 hours
restricted)
Sit
Stand / Walk
Employer Notified of Capacities?
Yes No
Perform work from ladder
Climb ladder
Modified duty available? Yes No
Climb stairs
Date of contact: ______/______/______
Twist
Name of contact: _________________________
Bend / Stoop
Notes:
Squat / Kneel
Crawl
Reach
Left, Right, Both
Work above shoulders
L, R, B
Note to Claim Manager:
Keyboard
L, R, B
Wrist (flexion/extension) L, R, B
Grasp (forceful)
L, R, B
Fine manipulation
L, R, B
Operate foot controls
L, R, B
Vibratory tasks; high impact L, R, B
Vibratory tasks; low impact L, R, B
Lifting / Pushing
Never
Seldom
Occas.
Frequent
Constant
May need assistance returning to work
Example
50
20 l
10
0
0
lbs
bs
lbs
lbs
lbs
New diagnosis:___________________________
Lift
L, R, B
____ lbs
____ lbs
____ lbs
___ lbs
____
lbs
Opioids prescribed for:
Acute pain or
Carry
L, R, B
____ lbs
____ lbs
____ lbs
___ lbs
____
lbs
Chronic pain
Push / Pull
L, R, B
____ lbs
____ lbs
____ lbs
___ lbs
____
lbs
Worker progress: As expected / better than expected
Next scheduled visit in: ___days ___weeks or Date: ___/___/___
(
Slower than expected
address in chart notes)
Treatment concluded, Max. Medical Improvement (MMI)
Any permanent partial impairment? Yes No Possibly
Current rehab:
PT
OT
Home exercise
If you are qualified, please rate impairment for your patient
Other (
) _______________
e.g., Activity Coaching
Will rate Will refer Request IME
Surgery:
Not Indicated
Possible
Care transferred to: ___________________________________
Planned
Date:
____/____/____
Consultation needed with: ______________________________
Completed
Date:
____/____/____
Study pending: _______________________________________
Copy of APF given to worker
Discussed three key messages on back of form with patient
Signature: _____________________________________________
_____/_____/_____
(
) _____-______________
Doctor ARNP
PA-C
Date
Phone
F242-385-000 Activity Prescription Form (APF) 11-2014
Index: APF
RESET
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