Physician additional 2026

1. Click ‘Get Form’ to open the physician additional form in the editor.
2. Begin by filling out the identifying information section. Enter the Board Claim Number, Employee's Last Name, First Name, M.I., Date of Injury, and SSN or Board Tracking Number.
3. In section A, provide details about the County of Injury and the name and address of your counsel if represented.
4. Move to section B to identify the currently authorized treating physician. Fill in their name and address.
5. Indicate whether you are requesting a Change of Physician or Additional Treatment by completing section C. Specify the names and addresses of the new physicians as needed.
6. In section D, certify the existence of a valid fee contract if applicable.
7. Finally, complete section E by certifying that all parties have been notified and sign with your details including date and contact information.

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