Provider Initial Report (PIR) Requirements

To facilitate the claim process, ensure the Provider Initial Report (PIR) is:

Filled out completely, leaving areas blank may delay processing of the claim and interrupt the processing of your bills for payment. If the condition is a disease, enter “N/A” for “not applicable” in both of the following boxes:

  • Date of injury
  • Time of injury

Be as specific as possible.

  • Include a complete diagnosis and the appropriate Common Diagnostic Codes (ICD-10 codes). Be clear about the specific body site and the definition of the injury.
  • If your patient is unable to perform any work due to the injury or disease, estimate how much time the injured worker will lose due to the injury.
  • Must be signed by both you and your patient.

Submit promptly with copies of the:

  • History and Physical
  • Emergency room evaluation or your office notes

Helpful Links:

  • Additional information is available on the Labor & Industry website here.
  • The PIR form can be downloaded from the Labor & Industry website.
  • Labor & Industry also provides additional guidance for billing Self-Insured Employers.

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