Assessment Request Form - L&I Step 1 of 2 50% InstagramThis field is for validation purposes and should be left unchanged.Your Company(Required)Requester(Required) Your Given Name Your Family Name Your Referring Provider Number or VOC Id NumberYour Job TitleYour Email(Required) Enter Email Confirm Email Your Phone(Required)Are you to receive a final report?(Required) No Yes Claim Manager(Required) First Name Family Name In order to avoid ErgoFit Consulting invoicing your company instead of L&I, please ensure the Claim Manager has authorized the following billing codes 0389R, 0390R, 0391R, 0392R, & 0393R. Has Claim Manager approved the above codes yet?(Required) No Yes Is Claim Manager to receive a final report?(Required) No Yes Claim Manager Phone(Required)Claim Manager Fax(Required)Additional Contact First Name Family Name Additional Contact Email Enter Email Confirm Email Additional Contact PhoneIs Additional Contact to receive a final report? No Yes Injured Worker InformationEvaluation Type(Required) Ergonomic Evaluation Job Modification Work From Home(Required)This is a work from home / remote / telecommuting employee? Yes No Contact to Schedule:(Required) Worker Directly Worker's Manager (no employee contact) Me / My company (no client contact) Other Purpose(Required)Please be specific as to what needs to be accomplished or learned.Claim Number(Required)Claim Status(Required)Date of Injury(Required) Month Day Year Prior Authorization Number(Required)If you do not have this number, please get from Claim Manager.Worker's Name(Required) First Name Family Name Worker's Email(Required) Enter Email Confirm Email Worker's Phone(Required)Workers Job TitleHas a Job Analysis previously been performed?(Required) No Yes Upload Additional InformationUpload any additional information (previous job analysis, doctor's note, etc.) in .pdf, .doc or .docx format. Maximum Number of Files: 3 Maximum File Size: 25MB Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 25 MB, Max. files: 3. Diagnosis(Required)Accepted Condition(Required)Previous Attempts at Modification(Required)Vocational Status(Required)Restrictions(Required)Pertinent History(Required)Company / EmployerOnsite ContactOnsite Contact if different than the injured worker. Example: Manager, Human Resources, Facilities, etc. First Name Family Name Onsite Contact Email Enter Email Confirm Email Onsite Contact PhoneIs Onsite Contact to receive a final report? No Yes Evaluation Location Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Additional Comments / Information
