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Click ‘Get Form’ to open the designated physician form in the editor.
Begin by entering your personal information in the EMPLOYEE section. Fill in your name, street address, city, state, zip code, date of birth, telephone number, and social security number.
Next, provide details about your employer at the time of injury or last exposure. Include the employer's name, street address, city, state, and zip code.
In the NATURE OF INJURY OR OCCUPATIONAL DISEASE section, describe your injury or disease clearly. Also, indicate the DATE OF INJURY OR LAST EXPOSURE.
Identify your FIRST DESIGNATED PHYSICIAN by filling in their name and contact information including street address, city, state, zip code, and telephone number.
Review the MEDICAL INFORMATION RELEASE section. Ensure you understand what you are consenting to before signing and dating this section.
Finally, complete the MEDICAL PAYMENT OBLIGOR section with their name and contact details before submitting the form as required.

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