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COMMONWEALTH OF KENTUCKY DEPARTMENT OF WORKERS CLAIMS 1270 LOUISVILLE ROAD FRANKFORT, KENTUCKY 40601 Claim No. Form 113 Designation of Physician Revised 81596 NOTICE OF DESIGNATED PHYSICIAN EMPLOYEE:

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How to fill out notice of designated physician

How to fill out a notice of designated physician:

01

Start by accessing the appropriate form. This form can usually be found on the website of the relevant authority, such as a state department of labor or workers' compensation board.

02

Begin filling out the form by providing your personal information. This typically includes your name, address, phone number, and email address. Make sure to fill in all the required fields accurately.

03

Next, you will need to identify your employer. This may involve providing the name of your company, their address, and contact information. Double-check that this information is correct before proceeding.

04

Specify the purpose of the notice by indicating that it is for designating a physician. This helps ensure that your request is properly processed and directed to the appropriate department.

05

Provide the details of the designated physician. This includes their name, specialty, address, and contact information. It is crucial to make sure that the physician you designate is certified and authorized to treat your specific medical condition or injury.

06

Indicate whether you have already received medical treatment for your condition. If you have, include the relevant details such as the date of the initial treatment and the name of the treating physician.

07

Review the completed form and make any necessary revisions. Ensure that all the information provided is accurate and up to date. Incorrect or incomplete information could lead to delays or complications in your medical treatment.

Who needs a notice of designated physician?

Employers and employees involved in workers' compensation claims or workplace injuries typically require a notice of designated physician. It is vital for employees seeking medical treatment related to an occupational injury or illness to notify their employer of the physician they have chosen to receive treatment from. Likewise, employers need this notice to ensure that appropriate medical care is provided to their employees and to comply with legal requirements related to workers' compensation.

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