Yakimahealth.com - Transfer of Care

Transfer of Care
Complete form and return to Department of Labor and Industries
Fax – 360-902-4567

Or

Mail to:
Department of Labor and Industries
Claims Section
PO Box 44292
Olympia WA 98504-4291
Claim Number:
Please Transfer my case
Date (changed health care providers)
Name of Current Provider
Provider ID #/NPI #
Name of New Provider
Provider ID #/NPI #
Address of New Provider Street

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for Transfer:
Claimant's Name
Today's Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Claimant's Signature
Should be Empty: