Activity Prescription Form (APF)

Billing Code: 1073M (Guidance on back)

Reminder: 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.

State Fund Claim:

Department of Labor and Industries

PO Box 44291 Olympia WA 98504-4291

Fax to claim file: 360-902-4567

Self-Insured Claims:

Contact the Self Insured Employer (SIE)/Third Party Administrator (TPA)

For a list of SIE/TPAs, go to www.Lni.wa.gov/SelfInsured

 

 Discuss your patient’s role in their recovery

Research has shown that returning to activity (including lighter work) speeds recovery and reduces the risk of becoming disabled from most work-injuries. In addition to providing good clinical care, it is  important to setexpectations for a good recovery and assure patients understand the importance of doing their part. Take just a couple minutes during an initial office visit to explain the following (check each one as you complete it):

 Key Messages

1.  “You must help in your own recovery…

• ”Only you can ensure your own successful recovery.
• It’s your job (and my expectation) that you follow activity recommendations (both at home and at work).

 2. “Activity helps recovery…”

•  Bodies heal best with activity that you can safely do, and need to do, to recover.

• Incrementally increase the activity you do a little bit, each day.

• Some discomfort is normal when returning to activities after an injury. This is not harmful, and is different from pain that indicates a setback.

 3. “Early and safe return to work makes sense…”

•  Return to work is one of the goals of treatment.The longer you are off work, the harder it is to get back to your original job and wages.  

• Even a short time off work takes money out of your pocket because time loss payments do not pay your full wage.