Get the free Form 123 - Physician s Initial Report of Work Injury or Occupational Disease - labor...

Form3073/1/12 STATEOFUTAH?LABORCOMMISSION AdjudicationDivision 160East300South?3rdFloor P.O. Box146615 SaltLakeCity,Utah841146615 Phone:(801)5306800Fax:(801)5306333 MEDICALTREATMENTPROVIDERLIST ClaimantName

How to fill out form 123 - physician

How to fill out form 123 - physician?

1. Review the instructions provided with form 123 - physician to understand the requirements and gather all necessary information.
2. Complete the personal information section accurately, including your name, address, contact information, and any other requested details.
3. Provide the required medical information, such as your current medical condition, history, and any relevant medications or treatments.
4. Answer all questions on the form truthfully and to the best of your knowledge, ensuring that all sections are filled out completely.
5. If there are any specific sections that you are unsure about or require additional clarification, consult with your physician or healthcare provider for guidance.
6. Once the form is filled out, review it carefully to check for any errors or missing information. Make any necessary corrections before submitting it.

Who needs form 123 - physician?

1. Form 123 - physician is typically needed by individuals who require medical attention or treatment.
2. It may be required by patients visiting a new healthcare provider or undergoing a medical evaluation or examination.
3. Insurance companies or government agencies may also request form 123 - physician to assess eligibility for certain benefits or services.
4. The specific circumstances and requirements for needing form 123 - physician will vary depending on the situation and the organization or entity requesting the form.

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What is form 123 - physician?

Form 123 - physician is a document used to report medical information about physicians.

Who is required to file form 123 - physician?

Form 123 - physician must be filed by healthcare organizations or institutions that employ or contract with physicians.

How to fill out form 123 - physician?

To fill out form 123 - physician, the healthcare organization or institution needs to provide the required medical information about the physicians, such as their names, specializations, qualifications, and any disciplinary actions.

What is the purpose of form 123 - physician?

The purpose of form 123 - physician is to collect and report accurate and up-to-date information about physicians for regulatory and informational purposes.

What information must be reported on form 123 - physician?

On form 123 - physician, the healthcare organization or institution must report information such as the physician's full name, contact details, medical qualifications, areas of specialization, licenses, certifications, and any past disciplinary actions.