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Designated physician form 2025

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Form 113 is a designation document for employees in Kentucky to select their designated physician for work-related injuries or diseases. It includes sections for employee and employer information, details about the injury, and consent for medical information release. The form must be submitted to the medical payment obligor within ten days of treatment initiation, and outlines the responsibilities of the designated physician in coordinating care.

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2003	4.8 Satisfied (95 Votes)

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What is DWC form 9783?

You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met.

What is a physician statement form?

An Attending Physician Statement (APS) is a form questionnaire from the insurance company that your treating doctor must complete. The purpose of the APS is for your doctor to certify your inability to work.

What not to say to a workers comp doctor?

What You Shouldnt Tell Your Workers Comp Doctor Never lie about prior injuries, pre-existing conditions, or medical history. Never lie about the extent of your workplace injury or how it happened. Do not exaggerate your symptoms, including pain or functionality.

Who might be asked to fill out a physicians statement?

In order to be effective, an Attending Physician Statement must be completed by a doctor who knows you in person your insurer or agency will reach out to get information from a physician who has either treated you in the past or is currently providing treatment.

What is the physician statement?

An attending physician statement (APS) is a report by a physician, hospital, or medical facility that has treated, or is currently treating, a person seeking insurance. In traditional underwriting, an APS is one of the most frequently ordered additional sources of medical background information.

Who completes an attending physician statement?

This statement, filled out by your attending physician, provides the disability insurance company with vital data to assess the validity of your disability claim. The APS can influence the decision-making process significantly, making it crucial to ensure it is accurately and thoroughly completed.

What does it mean to pre designate a physician?

Prior to the injury your doctor agrees to treat you for work injuries or illnesses; Prior to the injury you provided your employer the following in writing: (1) notice that you want your personal doctor to treat you for a work-related injury or illness, and (2) your personal doctors name and business address.

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