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Get WA F242-385-000 2018-2024

Inder: Send chart notes and reports to L&I or SIE/TPA as required. Complete this form only when there are changes in medical status or capacities, or change in release for work status. Self-Insured Claims: Contact the Self Insured General info Employer (SIE)/Third Party Administrator (TPA) For a list of SIE/TPAs, go to www.Lni.wa.gov/SelfInsured Worker’s Name: Patient ID: Healthcare Provider’s Name (please print): Visit Date: Claim Number: Date of Injury: Diagnosis: Required: Work .

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