Washington Labor and Industries Prosthetic Device Request Form

• Category: Workers Compensation - Official
• State: Washington
• Control #: WA-SKU-3697
• Format: PDF

Description

Labor and Industries Prosthetic Device Request Form

Washington Labor and Industries Prosthetic Device Request Form is a document used by prosthetics and orthotics to apply for coverage of prosthetic devices from the Washington Department of Labor and Industries (L&I). There are two types of this form: 1) the Prosthetic Device Request Form (DR) and 2) the Orthotic Device Request Form (ODR). The DR is used to request coverage for prosthetic devices such as lower and upper limb prostheses, spinal outhouses, and custom cranial outhouses. The ODR is used to request coverage for orthotic devices such as ankle-foot outhouses, knee-ankle-foot outhouses, and cervical collars. Both forms must be completed and signed by the prosthetic or orthotic, the physician, and the patient or the patient’s representative. The form must also include the patient’s diagnosis, the medical necessity for the device, and the type of device requested.