Form LS-1 Request for Examination and/or Treatment

Request for Examination and/or
Treatment
Reset

U.S. Department of Labor

Employment Standards Administration
Office of Workers' Compensation Programs

Print

Part A - Authorization

>

Instructions to Employer. This page of the form must be completed in full, and
authorizes a physician of the employee's choice (*See item 2 below) to
examine and/or treat an employee, covered by the Federal Workers'
Compensation Act marked in the box at right, for accidental injury, illness or
disease arising out of and in the course of employment.

OMB No. 1215-0066

1. This Authorization is for
examination and/or
treatment under the
Workers' Compensation
Act marked below:

Mark either box A or B in item 7. The original and at least two copies of this form
are to be given to the physician. The physician is to complete the medical report
and the initial bill on the reverse, sending within ten days the original of the
report to the District Director and copies to the insurance company or employer
named in item 13. Subsequent and regular follow-up reports should be
submitted by the physician on Form LS-204 and/or in narrative reports,
whenever requested.
An employee may not select a physician who is currently not authorized by the
Department of Labor to provide medical care under the Act.

A

Longshore and Harbor
Workers' Compensation Act

B

Defense Base Act

C

Nonappropriated Fund

D

Outer Continental Shelf
Lands Act

Instrumentalities Act

2. Name and address of physician or medical facility authorized to provide medical service
* (The term "physician" includes doctors of medicine (MD), surgeons, podiatrists, dentists, clinical psychologists, optometrists, osteopathic
practitioners, and chiropractors. Payment for chiropractic services is limited to charges for physical examinations, related laboratory tests, x-rays to
diagnose a subluxation of the spine, and treatment consisting of manipulation of the spine to correct a subluxation demonstrated by x-ray. See 20
2. Name
and address of physician or medical facility authorized to provide medical service
CFR 702.404)
name:
*
country:
city:
line 1:
zip:
state:
line 2: uxation demonstrated

3. Employee's Name
First Name

4. Date of Injury (mm/dd/yyyy)

5. Occupation

4. Date of injury (mm/dd/yyyy)

5. Occupation

M.I. Last Name

6. Employee's
How accident
or illness occurred
3.
Name

7. You are authorized to provide medical services to the employee as follows:
A

If you believe the condition is related to the injury, or the employee's occupation, furnish office and/or hospital treatment as
necessary for the effects of this injury.

B

If you are in doubt as to whether the condition(s) found on examination is related to the injury, you are authorized to examine
the employee, using indicated non-surgical diagnostic studies, and should promptly advise those listed in item 13 whether you
believe the disability is due to the alleged injury. Pending further advice you may provide necessary conservative treatment.

You are requested to submit a written report of first treatment within 10 days to the District Director at the Office
named in item 12 below (See back of this form for Instructions as to medical report and the submission of your charges).
8. Signature and title of authorizing official (Sign all copies)

9. Name and address of employer
name:

meiibackmm
name

10. Telephone (Area code and local number)
12. Send one copy of your report to:

U.S. Department of Labor
Employment Standards Administration
Office of Workers' Compensation Programs

city:
st:

line 1:
line 2:

title

m1

ctry:

zip:

11. Date authorized (mm/dd/yyyy)
13. Name and address of insurance carrier or self-insured
employer to whom bill and copy of report are to be sent
name:
line 1:
line 2:

city:
st:
country:

zip:

Public Burden Statement
The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995, as amended. The
authority for requesting the following information is 20CFR 702.419. Use of this form is optional, however furnishing the information is required in order to
obtain and/or retain benefits. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is
Public Burden Statement
1215-0066. The time required to complete this information collection is estimated to average 65 minutes per response, including the time for reviewing
Public reporting burden for this collection of information is estimated to average 65 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
comments regarding
this burden regarding
estimate orthis
any burden
other aspect
of thisor
collection
of information,
including
suggestions
for reducing
this burden,
to the U.S.for
information.
Send comments
estimate
any other
aspect of this
collection
of information,
including
suggestions
Department
of burden,
Labor, Division
Longshore
and Harbor
Workers'
Compensation,
Roomand
C4315,
200 Workers'
Constitution
Avenue, N.W., Washington,
D.C.200
20210.
reducing
this
to the ofU.S.
Department
of Labor,
Division
of Longshore
Harbor
Compensation,
Room C4315,

Constitution Avenue, N.W., Washington,DO
D.C.
20210.
DO
NOT
SEND THE COMPLETED
FORM
TO THIS OFFICE
NOT
SEND
THE
COMPLETED
FORM TO THIS
OFFICE
Form LS-1
Rev. May 1998

Part B - Attending Physician's Report of Injury and Treatment

<

Instructions To Physician: This Initial report should be completed and submitted within 10 days. Mail the original to the
District Director (see Item 12 for address), and a copy to the company listed In Item 13. Subsequent reports should be made
regularly on form LS-204 and/or in narrative form while the employee is In your care. Please read item 7 on the front of this form.
Your Social Security Number is voluntary and is used for identification purposes only.
14. What history of injury or disease did employee give you?

15. Is there any history or evidence of pre-existing injury, disease, or physical impairment?
Yes - Please describe
No

16. What are your findings (include results of x-rays, laboratory tests, etc.)?

17. What is your diagnosis?

18. Do you believe the condition found was caused or aggravated by the employment activity described? (Please explain your
answer if there is doubt.)
No
Yes
Yes - Complete b, c, d
19a. Did injury require hospitalization?
No
20. Is additional hospitalization required?
b. Name of hospital
Yes
No
c. Date admitted (mm/dd/yyyy)
d. Date discharged
22. Date surgery performed (mm/dd/yyyy)
21. Surgery (If any, describe type)
23. What type of treatment did you provide other than hospitalization or surgery? 24. What permanent effects of the injury, if any,
do you anticipate?

26. Date(s) of treatment (mm/dd/yyyy)

25. Date of first examination
(mm/dd/yyyy)

27. Date of discharge from treatment
(mm/dd/yyyy)
29. Date employee able to resume work

28. Period of disability (if termination date unknown - so indicate)

(mm/dd/yyyy)

Total disability:

From

To

To light work

Partial disability:

From

To

To regular work

30. If employee is able to resume work, has he/she been advised?

No

Yes - Furnish date advised (mm/dd/yyyy)

31. If employee is able to resume only light work, indicate physical limitations and the type of work which can reasonably be
performed with these limitations.

32. Remarks and recommendation for future care, if indicated.

33. Do you specialize?

No

Yes - State specialty

34. Signature and typed name of physician

First Name

M.I. Last Name

36. Physician's social security number

35. Address
line1:
line2:
city:
st:

37. Date of this report (mm/dd/yyyy)

country:

zip:

38. Medical bill (Charges for your services may be presented in the space below or on your billhead stationery.)
Date or period
of treatment

Services and supplies must be itemized

Qty.
or
No.

Unit price
Cost

Per

Total

Amount