Get Ky Form 113 - Genex Services

Filling out the KY Form 113 - GENEX Services online is a crucial step for employees seeking to designate a physician for workplace-related injuries. This guide provides clear, step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to fill out the KY Form 113 - GENEX Services online.

1. Press the 'Get Form' button to access the KY Form 113 - GENEX Services and open it in an online editor.
2. Begin by entering your claim number at the top of the form. This is essential for associating the form with your case.
3. In the employee section, fill in your name, street address, city, state, and zip code. Also, provide your date of birth and telephone number for contact purposes.
4. Next, include your social security number to identify yourself uniquely in the system.
5. Proceed to the employer section and enter the name and address of your employer at the time of your injury or last exposure, including city, state, and zip code.
6. In the nature of injury or occupational disease section, provide a brief description of the injury or disease you are filing the claim for.
7. Specify the date of injury or last exposure in the respective field to ensure the timeline of your injury is documented.
8. In the designated physician section, fill in the name and address of your first designated physician, including their city, state, and zip code, as well as their telephone number.
9. Review the medical information release section and indicate your consent by signing and dating the form. This authorization allows the necessary parties to access your medical information related to your injury.
10. Complete the section for the medical payment obligor by providing their name, representative, address, and telephone number.
11. Finally, review all filled-out information for accuracy. Once confirmed, save your changes, and you can download, print, or share the form as needed.

Complete your KY Form 113 - GENEX Services online today to ensure timely processing of your designation.