Get Ls 204

Filling out the Ls 204 form is a crucial step in the process of requesting medical examination and treatment under the Workers' Compensation Act. This guide provides clear instructions to ensure you complete the form accurately and efficiently, helping you understand each component of the document.

Follow the steps to successfully complete the Ls 204 form online.

1. Click the ‘Get Form’ button to access the Ls 204 form and open it in your preferred editor.
2. Begin with Part A - Authorization. Fill in the name and address of the physician or medical facility authorized to provide services. Ensure the details are complete and correct as this section is essential for the authorized provider.
3. Next, enter the employee's name, date of injury, occupation, and describe how the accident or illness occurred. This information helps in establishing the context for the medical treatment request.
4. Proceed to section 7, where you will mark either box A or B to indicate whether treatment is necessary or if a diagnosis is required to determine the relationship between the condition and the injury.
5. Complete the signature and title of the authorizing official in section 8. Ensure that this is done before submitting the form as it is required for validation.
6. In section 9, provide the name and address of the employer. Ensure that all information is accurate to avoid delays in processing.
7. Enter the telephone number in section 10 and the date authorized in section 11, ensuring the format is mm/dd/yyyy.
8. Fill out section 12 with the address of the Office of Workers' Compensation Programs where the medical report needs to be sent.
9. Lastly, provide the name and address of the insurance carrier or self-insured employer in section 13, making sure to include all necessary information.
10. Once all sections are completed, review the entire form for accuracy before finalizing. You can then save changes, download, print, or share the form as necessary.

Complete your Ls 204 form online and ensure your request for examination and treatment is submitted accurately.