Form 113 PDF Details

For workers in Kentucky facing injuries or occupational diseases, navigating the healthcare aspects of workers' compensation claims can be complex. The 113 form, a crucial document issued by the Commonwealth of Kentucky Department of Workers' Claims, plays a pivotal role in this process. Revised on March 12, 2003, this two-sided form serves for the Notice of Designated Physician. It entails important sections where an employee must fill out personal information, details about the employer at the time of injury or last exposure, and specifics of the injury or occupational disease itself. At the heart of the form is the designation of a physician, chosen by the employee, who will oversee the medical care related to the work-related condition. This includes an authorization waiving privilege over medical information pertinent to the treatment of the injury or disease, thus allowing its release to specified parties like the employer, medical payment obligor, or legal representatives. The responsibility laid on the chosen physician ranges from initial treatment to coordinating any further medical intervention needed. Rules surrounding the designation allow for changing the physician under certain conditions but restrict multiple changes without consent from the medical payment obligor. With the submission deadline and the issuance of an identification card for medical services, the form underscores the structured process Kentucky employs to ensure injured workers receive the necessary medical attention through their workers' compensation claims.

QuestionAnswer
Form NameForm 113
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform 113, chiropractors, 113 form, FRANKFORT

Form Preview Example

FORM 113

Designation of Physician Revised 03-12-03

TWO-SIDED FORM

COMMONWEALTH OF KENTUCKY DEPARTMENT OF WORKERS’ CLAIMS 657 TO BE ANNOUNCED AVENUE FRANKFORT, KY 40601

Claim No.

NOTICE OF DESIGNATED PHYSICIAN

EMPLOYEE:

Name

Street Address

 

 

 

( )

 

City, State, Zip

 

Telephone Number

 

 

 

 

Date of Birth

Social Security Number

EMPLOYER AT TIME OF INJURY OR LAST EXPOSURE:

Name

Street Address

City, State, Zip

NATURE OF INJURY OR OCCUPATIONAL DISEASE:

DATE OF INJURY OR LAST EXPOSURE:

FIRST DESIGNATED PHYSICIAN:

Name

 

 

 

 

 

 

 

Street Address

 

 

 

 

(

)

 

City, State, Zip

Telephone Number

Accepted by:

MEDICAL INFORMATION RELEASE: I hereby waive any privilege I may have to restrict the release of information or written material reasonably related to the work-related injury/disease for which I have sought treatment, and I consent to the release of this information or written material to the medical payment obligor, my employer, Special Fund, Uninsured Employers’ Fund, or attorneys representing me or any of the parties named above.

Date

 

Employee Signature

MEDICAL PAYMENT OBLIGOR:

Name Of Obligor

Representative

Street Address

City, State, Zip

()

Telephone Number

Notice: The Workers’ Compensation Act requires the employer to pay for the medical services reasonably necessary for cure and relief from the effects of a workplace injury or disease.

The employee may choose the physician (including chiropractors, etc.) who treats him as “designated physician.” The designated physician is responsible for the coordination of the employee’s medical care and may refer the patient to consulting or treating physicians as required. Except in an emergency, all treatment must be performed by or on referral from the designated physician. The employee may not change his designated physician more than once without the medical payment obligor’s consent.

This form identifies the designated physician and must be returned to the medical payment obligor within ten (10) days after treatment begins. An identification card will be provided to the employee, and that card should be presented when medical treatment is required.

Inquiries shall be made to the listed representative of the medical payment obligor.

This form is not advance authorization from the workers’ compensation medical payment obligor for medical services.

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chiropractors writing process explained (stage 1)

2. After finishing the last part, go on to the next stage and complete the essential details in these fields - EMPLOYEE Date of Birth EMPLOYER AT, City State Zip, Name, Street Address City State Zip, Accepted by, Name Of Obligor Representative, Employee Signature, Telephone Number, and Telephone Number.

Stage number 2 of completing chiropractors

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