Pre-Job Modification Accommodation Assistant Application - Washington 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Worker Name and Claim Number(s) at the top of the form. Ensure that these details are accurate as they are essential for processing your application.
3. Indicate your Job Goal and check the appropriate box for the items needed, whether for a Retraining Plan or Job Goal. This helps clarify your request's purpose.
4. Attach required documents such as the attending provider’s statement of medical necessity, consult report, vendor bid, and signed ownership agreement. Use our platform to easily upload these files.
5. List specific equipment or training tools requested along with their costs in the Itemization of Costs section. Make sure to include vendor information accurately for payment processing.
6. Complete the Requestor’s Signature section and ensure all fields are filled out before submitting your application via fax to the claim file number provided.

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