Dol Form Ls 1 PDF Details

The Dol LS-1 form stands as a crucial document managed by the U.S. Department of Labor’s Office of Workers' Compensation Programs. It plays a pivotal role in facilitating medical examination and/or treatment for employees who suffer from accidental injuries, illnesses, or diseases that are associated with their job. Specifically designed under several acts including the Longshore and Harbor Workers' Compensation Act, Defense Base Act, Nonappropriated Fund Instrumentalities Act, and Outer Continental Shelf Lands Act, this form ensures that workers receive timely and appropriate medical care. The form, divided into two main parts, requires comprehensive details starting from the authorization by the employer to the attending physician's detailed report of injury and treatment. Employers are mandated to fill out the form accurately, authorizing a chosen physician—encompassing a wide range of medical professionals from doctors of medicine to chiropractors—to examine and treat the employee. The physician, on the other hand, is tasked with submitting a thorough medical report and an initial bill back to the District Director and other relevant entities, such as the insurance company or self-insured employer. The form mandates the submission of these details within specific time frames to streamline the process of claims and treatment, reinforcing the act's overarching goal to support injured workers' rights and well-being.

QuestionAnswer
Form NameDol Form Ls 1
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesls1 form, ls 1 form dol, ls form, ls forms

Form Preview Example

 

Request for Examination and/or

U.S. Department of Labor

 

Treatment

Office of Workers' Compensation Programs

 

 

 

 

 

 

 

 

Part A - Authorization

 

 

 

OMB No. 1240-0029

 

Instructions to Employer. This page of the form must be completed in full, and

1. This Authorization is for examination

 

authorizes a physician of the employee's choice (*See item below) to

 

and/or treatment under the Workers'

 

examine and/or treat an employee, covered by the Federal Workers'

 

Compensation Act marked below:

 

Compensation Act marked in the box at right, for accidental injury, illness or

 

 

 

 

 

 

disease arising out of and in the course or employment.

 

 

 

 

 

 

Mark either box A or B in item 7. The original and at least two copies of this form

A

Longshore and Harbor

 

 

Workers' Compensation Act

 

are to be given to the physician. The physician is to complete the medical report

B

 

 

 

 

and the initial bill on the reverse, sending within ten days the original of the

Defense Base Act

 

report to the District Director and copies to the insurance company or employer

 

 

 

 

 

named in item 13. Subsequent and regular follow-up reports should be

 

C

Nonappropriated Fund

 

submitted by the physician on Form LS-204 and/or in narrative reports,

 

Instrumentalities Act

 

 

 

 

whenever requested.

 

 

 

 

 

 

An employee may not select a physician who is currently not authorized by the

D

Outer Continental Shelf

 

 

Lands Act

 

Department of Labor to provide medical care under the Act.

 

 

 

 

 

 

 

 

 

 

 

 

2.Name and address of physician or medical facility authorized to provide medical service

* (The term ''physician'' includes doctors of medicine (MD), surgeons, podiatrists, dentists, clinical psychologists, optometrists, osteopathic practitioners, and chiropractors. Payment for chiropractic services is limited to charges for physical examinations, related laboratory tests, x-rays to diagnose a subluxation of the spine, and treatment consisting of manipulation of the spine to correct a subluxation demonstrated by x-ray. See 20

CFR 702.404)

name:

 

 

 

 

line1:

city:

 

line2:

st:

3. Employee's Name

4. Date of Injury (mm/dd/yyyy)

5. Occupation

6.How accident or illness occurred

7.You are authorized to provide medical services to the employee as follows:

A

B

If vou believe the condition is related to the iniury. or the employee's occupation, furnish office and/or hospital treatment as necessary for the effects of this injury.

If you are in doubt as to whether the condition(s) found on examination is related to the injury, you are authorized to examine

the employee, using indicated non-surgical diagnostic studies, and should promptly advise those listed in item 13 whether you believe the disability is due to the alleged injury. Pending further advice you may provide necessary conservative treatment.

You are requested to submit a written report of first treatment within 10 days to the District Director at the Office named in item 12 below (See back of this form for Instructions as to medical report and the submission of your charges).

8. Signature and title of authorizing official (Sign all copies)

9. Name and address of employer

 

 

name:

 

 

line1:

city:

 

line2:

st:

 

 

 

10. Telephone (Area code and local number)

11. Date authorized (mm/dd/yyyy)

 

12. Send one copy of your report to:

13. Name and address of insurance carrier or self-insured

 

employer to whom bill and copy of report are to be sent

U.S. Department of Labor

name:

 

Office of Workers' Compensation Programs

line1:

city:

 

line2:

st:

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 65 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Use of this form is optional, however furnishing the information is required in order to obtain and/or retain benefits (20CFR 702.419). Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, 200 Constitution Avenue, N.W., Room C-4315, Washington, D.C. 20210, and reference the OMB Control Number.

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE

Form LS-1

Rev. October 2010

Part B - Attending Physician's Report of Injury and Treatment

Instructions To Physician: This initial report should be completed and submitted within 10 days. Mail the original to the District Director (see Item 12 for address), and a copy to the company listed In Item 13. Subsequent reports should be made regularly on form LS-204 and/or in narrative form while the employee is in your care. Please read item 7 on the front of this form. Your Social Security Number is voluntary and is used for identification purposes only.

14.What history of injury or disease did employee give you?

15.Is there any history or evidence of pre-existing injury, disease, or physical impairment?

No

Yes - Please describe

16. What are your findings (include results of x-rays, laboratory tests, etc.)?

17. What is your diagnosis?

18.Do you believe the condition found was caused or aggravated by the employment activity described? (Please explain your answer if there is doubt.)

Yes

No

19a. Did injury require hospitalization?

No

Yes - Complete b, c, d

b. Name of hospital

c. Date admitted (mm/dd/yyyy)

d. Date discharged

20. Is additional hospitalization required?

Yes

No

21. Surgery (If any, describe type)

22. Date surgery performed (mm/dd/yyyy)

23.What type of treatment did you provide other than hospitalization or surgery? 24. What permanent effects of the injury, if any, do you anticipate?

25. Date of first examination

 

26. Date(s) of treatment (mm/dd/yyyy)

27. Date of discharge from treatment

(mm/dd/yyyy)

 

 

 

(mm/dd/yyyy)

 

 

 

 

28. Period of disability (if termination date unknown - so indicate)

 

29. Date employee able to resume work

Total disability:

From

To

 

To light work

 

 

Partial disability:

From

To

 

To regular work

 

 

 

30. If employee is able to resume work, has he/she been advised?

No

Yes - Furnish date advised (mm/dd/yyyy)

31.If employee is able to resume only light work, indicate physical limitations and the type of work which can reasonably be performed with these limitations.

32.Remarks and recommendation for future care, if indicated.

33. Do you specialize? No

Yes - State specialty

34. Signature and typed name of physician

35. Address and phone number

36. Physician's Federal Tax ID number

37. Date of this report (mm/dd/yyyy)

38. Medical bill (Charges for your services may be presented in the space below or on your billhead stationery.)

Date or period

of treatment

Services and supplies must be itemized

Qty.

or No.

Unit price

Cost Per

Amount

Total

How to Edit Dol Form Ls 1 Online for Free

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Be mindful while completing this document. Make certain all necessary blanks are completed properly.

1. To start with, once filling out the ls 1 form dept of labor, start with the page that has the next blanks:

Filling in part 1 of ls 1 dol

2. After this array of fields is done, you'll want to insert the required details in If vou believe the condition is, If you are in doubt as to whether, You are requested to submit a, Signature and title of, Name and address of employer, name, line, line, city, Telephone Area code and local, Date authorized mmddyyyy, Send one copy of your report to, Name and address of insurance, employer to whom bill and copy of, and US Department of Labor Office of allowing you to move on to the third stage.

If vou believe the condition is, line, and Date authorized mmddyyyy inside ls 1 dol

Be very mindful when completing If vou believe the condition is and line, because this is the part where a lot of people make mistakes.

3. Completing Instructions To Physician This, Is there any history or evidence, Yes Please describe, What are your findings include, What is your diagnosis, Do you believe the condition, answer if there is doubt, Yes, a Did injury require, Yes, Complete b c d, Is additional hospitalization, b Name of hospital c Date admitted, d Date discharged, and Surgery If any describe type is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

The way to fill in ls 1 dol step 3

4. This specific part arrives with the following fields to fill out: Date of first examination, Dates of treatment, mmddyyyy, Date of discharge from treatment, mmddyyyy, mmddyyyy, Period of disability, if termination date unknown so, Date employee able to resume work, Total disability, Partial disability, From, From, To light work To regular work, and If employee is able to resume.

ls 1 dol writing process outlined (step 4)

5. This pdf needs to be concluded within this segment. Here one can find an extensive set of form fields that need correct details for your document submission to be complete: of treatment, Services and supplies must be, or No, Cost, Per, Amount, and Total.

Completing part 5 in ls 1 dol

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