Form 113 2026

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Form 113 is a designation document for employees in Kentucky to select their designated physician for work-related injuries or diseases. It includes sections for employee and employer information, details about the injury, and consent for medical information release. The form must be submitted to the medical payment obligor within ten days of treatment initiation, and it outlines the responsibilities of the designated physician in coordinating care.

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Click ‘Get Form’ to open it 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. Then enter the DATE OF INJURY OR LAST EXPOSURE.
Identify your FIRST DESIGNATED PHYSICIAN by filling in their name and contact details including street address, city, state, zip code, and telephone number.
Review the MEDICAL INFORMATION RELEASE statement and sign it to consent to the release of medical information related to your treatment.
Finally, ensure all fields are completed accurately before submitting the form back to the medical payment obligor within ten days after treatment begins.

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What does first designated physician mean?

FAQs. What does it mean to pre-designate a physician? Pre-designating a physician means choosing a doctor in advance to treat you in the event of a work-related injury. What not to say to a workers comp doctor? Avoid downplaying your symptoms or exaggerating your injuries; be honest and clear.

What is the highest level of physician?

Levels of doctors Intern. Junior resident. Senior resident. Chief resident. Fellow. Attending physician. Head of department. Medical director. National average salary: $239,469 per year Primary duties: A medical director is the highest level of a doctor, and they hold the most power and responsibility in a hospital or clinic.

What is form 1139 used for?

Corporations (other than S corporations) use this form to apply for a quick refund of taxes from: the carryback of a net operating loss (or a loss from operations of a life insurance company), the carryback of a net capital loss, the carryback of an unused general business credit, or.

What is a 113 designation of physician?

The Notice of Designated Physician Form This is also referred to as workers compensation Form 113. This form is sent to you by the workers comp insurance company. Youll use this form to specify a certain doctor to as your medical gatekeeper.

What is the class code for physicians?

For physicians, Class Code 8832 is most commonly used. This code applies to medical practices like general physicians, specialists, and clinics. It reflects the risk associated with providing healthcare services in a clinical environment, such as potential exposure to bloodborne pathogens and patient handling.

form 113

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What not to say to a workmans comp doctor?

What Not to Say to a Workers Comp Doctor Avoid Downplaying Your Injury: Dont minimize your pain or discomfort. Dont Speculate on Recovery Time: Do not make guesses about how quickly you will recover. Stay Away from Absolute Statements: Do not use words like always or never when describing your symptoms.

What is the 60 month plan for Chapter 13?

A 60 month plan is required if the debtors gross income in the six months prior to filing is above the median income for the family size in the state. Plans cannot exceed 60 months. That means that any debts that must be paid must be able to be paid within 60 months.

Form 113 2026

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What does first designated physician mean?

What is the highest level of physician?

What is form 1139 used for?

What is a 113 designation of physician?

What is the class code for physicians?

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What not to say to a workmans comp doctor?

What is the 60 month plan for Chapter 13?

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