Part A is the Authorization. Part B is the Attending Physician's Report of Injury and Treatment.
Item 7: mark either box A or B.
Copies: the original and two copies of this form are to be given to the physician.
Part B: this initial report should be completed and submitted within 10 days.
Physician: an employee may not select a physician who is currently not authorized by the Department of Labor to provide medical care under the Act.
Use: use of this form is optional, however furnishing the information is required in order to obtain and/or retain benefits (20CFR 702.419).
| Question | Answer |
|---|---|
| Form Name | Form LS-1 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 90 |
| Avg. time to fill out | 15 min |
| Edition | Rev Nov 2023 |
| Issuing agency | U.S. Department of Labor Office of Workers' Compensation Programs |
| Other names | LS-1, LS1, Form LS-1, DOL Form LS-1, DOL LS-1, Request for Examination and/or Treatment |
| Official source | Form LS-1 (Rev. Nov 2023), U.S. Department of Labor Office of Workers' Compensation Programs |
Dol Form Ls 1 isn’t the one you’re looking for?