INSTRUCTIONS: 1) form to be completed by physician; 2) copy of completed form to be sent to insurance carrier with bill 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your details in the PHYSICIAN section. Fill in your name, phone number, treatment facility, and registered email.
3. In the CARRIER section, provide the insurance company name and mailing address, including city and state.
4. Next, complete the PATIENT section with the employee's first name, last name, social security number (or other), date of birth, gender, and telephone number.
5. Fill out the EMPLOYER section with the employer's name and address along with their telephone number.
6. In the HISTORY section, document the date of injury and last date worked. Include a detailed statement from the employee regarding the cause of injury or illness.
7. Proceed to EXAMINATION. Provide a diagnosis related to the industrial claim along with an ICD code. Indicate if treatment is required due to this injury.
8. Add any additional comments in the COMMENTS section before finalizing your submission date.

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