Form 123 - Physician's Initial Report of Work Injury or Occupational ... 2026

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering the Carrier File Number and the Name of the Injured Person at the top of the form.
  3. Fill in the Social Security Number, Home Address, City/State/Zip, and Home Phone Number for accurate identification.
  4. In the section regarding your injury, provide details about how the accident occurred, including parts of the body injured and results.
  5. List all doctors you have been treated by, including their full names and addresses in chronological order.
  6. Indicate whether you asked your present doctor for a referral and specify if you would like permission to change doctors.
  7. Provide reasons for wanting to change doctors in the designated area before mailing this request to your insurance carrier.

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