Job Modification Assistance Application
Download a blank fillable Job Modification Assistance Application in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Job Modification Assistance Application with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3Mail completed application form to:
JOB MODIFICATION
Department of Labor & Industries
ASSISTANCE APPLICATION
Claims Section
PO Box 44291
Olympia WA 98504-4291
Date of injury
Claim number
One vendor per application form
Injured worker’s name
Accepted diagnosis
Vocational counselor/job modification consultant
Provider number
Firm’s name
Phone number
Address
Fax number
City
State
ZIP+4
Worker’s Job title
Employer name
Phone number
RESTRICTIONS
DESCRIPTION OF JOB MODIFICATION
ITEMIZATION OF COSTS:
REQUIRED
Labor and Industries (L&I) provider
number required for payment.
DOCUMENTATION
Equipment
If equipment vendor does not have a
Job modification narrative
L&I provider number – Call:
or consultation report
Provider Accounts
Tools
(360) 902-5140
AND
Ownership agreement
Other
For payment, submit bill on pink
“Statement for Retraining and Job
AND
Modification Services” form (F245-
Assembly, installation & delivery
030-000). Attach copy of approved
Bids (2 bids if single item
application.
over $2,500)
Tax
Vendor name
$0.00
$
Total
Address
Employer’s portion of costs
City
State
ZIP+4
State Fund or Self-Insured portion of costs
Provider number
Phone number
Date
Vocational counselor or consultant signature
Employer signature (if contributed to costs)
For Dept Use Only
0380R
Approve
Authorization code (
)
Authorization amount
Disapprove
entered on AUTH
entered on CLOG
Date
Signature authority
Index:
1
F245-346-000 job modification assistance application p
12-2008
JMOD
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal