Manual Non-Portal Submission

Download the WISeR intake form for Washington State requests.

1. You may fill this interactive form in a PDF Reader/viewer, (like Adobe Acrobat Reader, or a built-in browser viewers that let you open, read, print, and fill forms). 
2. After filling the form, save in this format :WISeR-Intake-Form_Date_Name.pdf
3. Then print
4. Include form with supporting medical record documents for review.
5. Send via mail or fax to:

This request document and medical record documentation is required and may be submitted via fax, mail or electronic portal. All fields are REQUIRED unless otherwise noted. Incomplete or illegible handwritten requests will be non-affirmed.