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INSTRUCTIONS: 1) form to be completed by physician; 2) copy of completed form to be sent to insurance carrier with bill 2026
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How to use or fill out the Physician’s Initial Report of Work Injury or Occupational Disease Form 123
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering your details in the PHYSICIAN section. Fill in your name, phone number, treatment facility, and registered email.
- In the CARRIER section, provide the insurance company name and mailing address, including city and state.
- 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.
- Fill out the EMPLOYER section with the employer's name and address along with their telephone number.
- 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.
- 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.
- Add any additional comments in the COMMENTS section before finalizing your submission date.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2019 | 4.8 Satisfied (94 Votes) |
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