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Transfer Of Care Intake Form
Note: If you are a Federal worker injured on the job, we are unable to see you for your injury. Please go to
Claimant's Corner | OFFICE OF WORKERS' COMPENSATION PROGRAMS
to find a provider in your area.
Please Check One:
*
New Injury
Reopening*
Transfer Of Care*
Which Location Do You Prefer?
*
Vancouver Location
Longview Location
No Preference
Claim Number:
Full Name:
*
Last 4 SSN:
Date of Birth:
*
Email Address:
*
Phone Number:
*
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