Form LS-1 Request for Examination and/or Treatment

Request for Examination and/or
Treatment

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U.S. Department of Labor

Office of Workers' Compensation Programs

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 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 or employment.

OMB No. 1240-0029

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
CFR 702.404)

name:
line1:

city:

line2:

st:

3. Employee's Name

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

5. Occupation

6. How accident or illness occurred

7. You are authorized to provide medical services to the employee as follows:
If vou believe the condition is related to the iniury. or the employee's occupation, furnish office and/or hospital treatment as
A
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:
line1:

city:

line2:

st:

10. Telephone (Area code and local number)

11. Date authorized (mm/dd/yyyy)

12. Send one copy of your report to:

13. Name and address of insurance carrier or self-insured
employer to whom bill and copy of report are to be sent

U.S. Department of Labor
Office of Workers' Compensation Programs

name:
line1:

city:

line2:

st:

Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a
valid OMB control number. 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. Use of this form is optional, however furnishing the information is required in order to obtain and/or retain benefits (20CFR 702.419). Send
comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S.
Department of Labor, 200 Constitution Avenue, N.W., Room C-4315, Washington, D.C. 20210, and reference the OMB Control Number.

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE
Form LS-1

Rev. October 2010

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
19a. Did injury require hospitalization?
b. Name of hospital
c. Date admitted (mm/dd/yyyy)

No

Yes - Complete b, c, d

20. Is additional hospitalization required?
Yes

No

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)

29. Date employee able to resume work

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

From

To

Partial disability:

From

To

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

27. Date of discharge from treatment
(mm/dd/yyyy)

To light work
To regular work
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

36. Physician's Federal Tax ID number

35. Address and phone number

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

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