Form 113 – Fill Out and Use This PDF

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.