Form F242-243-000 "Notice of Occupational Disease or Infection" - Washington

What Is Form F242-243-000?

This is a legal form that was released by the Washington State Department of Labor and Industries - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2012;
  • The latest edition provided by the Washington State Department of Labor and Industries;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form F242-243-000 by clicking the link below or browse more documents and templates provided by the Washington State Department of Labor and Industries.

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Download Form F242-243-000 "Notice of Occupational Disease or Infection" - Washington

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Department of Labor and Industries
NOTICE OF OCCUPATIONAL
Claims Section
DISEASE OR INFECTION
PO Box 44291
Olympia WA 98504-4291
Medical Provider: If you examined this worker and diagnosed him/her with an occupational disease or infection:
1.) Inform the worker of their right to file an occupational disease claim. If the worker requests, complete a Report of
Industrial Insurance or Occupational Disease form and follow its mailing instructions.
If a Report of Industrial Insurance or Occupational Disease form is not completed by you and the worker:
1.) Inform the worker that he or she must file a claim within two years from the date this form is signed and a copy is provided
to him or her.
2.) Complete and sign this form.
3.) Provide a copy of this form to the worker.
4.) Mail the original of this form to the address above.
Note to medical provider: Please have the worker help you complete this section of the form
Worker’s name
Phone number
Social Security number (ID only)
Date of birth
Sex
Worker’s occupation
Current home address
City
State
ZIP
Mailing address if different
City
State
ZIP
Business name of employer where most recent injurious exposure or activity occurred
Phone number
Employer’s address
City
State
ZIP
Length of employment
From: (mm/yy)
To: (mm/yy)
Date of last injurious exposure or activity
with this employer?
Name of previous employers
From: (mm/yy)
To: (mm/yy)
Describe the exposure or activity which
appears to have caused the occupational
disease or infection
Medical Provider: Please complete the section below in full
Medical provider’s name
Phone number
Address
City
State
ZIP
Provisional diagnosis ( Use both standard description and ICD code)
Date of first treatment (mm/yy)
Provider account/NPI
number
Type of exposure which caused the
occupational disease/injury (Such as
noise, specific chemicals, toxic
substances, specific job-related activities,
bacterial or viral infections)
I certify that I have examined this worker and have determined that he or she has a disease or infection (diagnosed above)
caused by his or her occupation. I have advised the worker of his/ her right to file a claim for workers’ compensation benefits.
I also explained that claims must be filed within two years from the date this form is signed and provided to the worker.
Today’s date (mm/dd/yy)
Signature
Licensed physician
must sign
F242-243-000 Notice of Occupational Disease or Infection 12-2012
Original – L&I
Copy – Worker
Department of Labor and Industries
NOTICE OF OCCUPATIONAL
Claims Section
DISEASE OR INFECTION
PO Box 44291
Olympia WA 98504-4291
Medical Provider: If you examined this worker and diagnosed him/her with an occupational disease or infection:
1.) Inform the worker of their right to file an occupational disease claim. If the worker requests, complete a Report of
Industrial Insurance or Occupational Disease form and follow its mailing instructions.
If a Report of Industrial Insurance or Occupational Disease form is not completed by you and the worker:
1.) Inform the worker that he or she must file a claim within two years from the date this form is signed and a copy is provided
to him or her.
2.) Complete and sign this form.
3.) Provide a copy of this form to the worker.
4.) Mail the original of this form to the address above.
Note to medical provider: Please have the worker help you complete this section of the form
Worker’s name
Phone number
Social Security number (ID only)
Date of birth
Sex
Worker’s occupation
Current home address
City
State
ZIP
Mailing address if different
City
State
ZIP
Business name of employer where most recent injurious exposure or activity occurred
Phone number
Employer’s address
City
State
ZIP
Length of employment
From: (mm/yy)
To: (mm/yy)
Date of last injurious exposure or activity
with this employer?
Name of previous employers
From: (mm/yy)
To: (mm/yy)
Describe the exposure or activity which
appears to have caused the occupational
disease or infection
Medical Provider: Please complete the section below in full
Medical provider’s name
Phone number
Address
City
State
ZIP
Provisional diagnosis ( Use both standard description and ICD code)
Date of first treatment (mm/yy)
Provider account/NPI
number
Type of exposure which caused the
occupational disease/injury (Such as
noise, specific chemicals, toxic
substances, specific job-related activities,
bacterial or viral infections)
I certify that I have examined this worker and have determined that he or she has a disease or infection (diagnosed above)
caused by his or her occupation. I have advised the worker of his/ her right to file a claim for workers’ compensation benefits.
I also explained that claims must be filed within two years from the date this form is signed and provided to the worker.
Today’s date (mm/dd/yy)
Signature
Licensed physician
must sign
F242-243-000 Notice of Occupational Disease or Infection 12-2012
Original – L&I
Copy – Worker