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PDFWAC 296-16A-050

How do I apply for reimbursements?

(1) To request reimbursements, fill out the appropriate stay-at-work reimbursement form we will supply you that is available on our web site. One form is for wage reimbursement and there is a separate form for all other reimbursements. Once you have completed the form or forms, mail or fax them to us at the address or fax number provided on the form.
(2) For all stay-at-work reimbursements, in addition to the completed forms, we also need:
(a) Documentation from the attending provider restricting your worker from his or her usual work for the dates you are requesting reimbursement;
(b) A written description of the light duty or transitional work that enables the attending provider to relate the physical activities of the work to your worker's restrictions;
(c) The attending provider's written approval releasing the worker to do that work.
(3) For wage reimbursement, we need documentation such as payroll records and time cards that verify the dates worked and basic gross wages paid.
(4) For tools and equipment, clothing, and training, we need itemized receipts showing your expenses.
[Statutory Authority: RCW 51.04.020 and 51.32.090. WSR 12-09-056, ยง 296-16A-050, filed 4/17/12, effective 5/21/12.]
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