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Form 123 - Physician's Initial Report of Work Injury or Occupational ... 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the Carrier File Number and the Name of the Injured Person at the top of the form.
- Fill in the Social Security Number, Home Address, City/State/Zip, and Home Phone Number for accurate identification.
- In the section regarding your injury, provide details about how the accident occurred, including parts of the body injured and results.
- List all doctors you have been treated by, including their full names and addresses in chronological order.
- Indicate whether you asked your present doctor for a referral and specify if you would like permission to change doctors.
- Provide reasons for wanting to change doctors in the designated area before mailing this request to your insurance carrier.
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See more Form 123 - Physician's Initial Report of Work Injury or Occupational ... versions
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2019 | 4.8 Satisfied (116 Votes) |
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Related links
Form 123 must be completed and filed for every initial visit for which a bill is generated, including first aid, when the worker reports that his or her medicalRead more
Form 123. Physicians Initial Report of Work Injury or. Occupational Disease. INSTRUCTIONS: 1) form to be completed by physician; 2) copy of completed form toRead more