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Clear All Fields v010113 Personal Physician Designation Form DWC FORM 9783 In the event you sustain an injury or illness related to your employment, you may be treated for such injury or illness by.

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Related content

PREDESIGNATION OF PERSONAL PHYSICIAN
by your personal medical doctor (M.D.), doctor of osteopathic medicine (D.O.) or medical...
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PREDESIGNATION OF PERSONAL PHYSICIAN
by your personal medical doctor (M.D.), doctor of osteopathic medicine (D.O.) or medical...
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Name, date, and address. Date and location of injury. Brief description of injury. List of injured body parts. Social Security Number.

(1) Notice of the predesignation of a personal physician is in writing, and is provided to the employer prior to the industrial injury for which treatment by the personal physician is sought. ... (3) The employee's personal physician agrees to be predesignated prior to the injury.

Check only one of the two boxes at the top of the page: ... Enter in the applicable spaces the hiring contractor's federal tax ID number and address. ... Enter in the applicable spaces the independent contractor's federal tax ID number, address.

Employee injured. while at work. Provide treatment. Notify MOM of the. accident. Pay medical leave. wages and medical. expenses. Ensure employee submits. the completed application. form for him to claim. compensation under WICA. Send medical report form. and pay medical report fees. Ensure employee attends. all medical appointments.

3. The employer files the claim. Usually, the employer is responsible for submitting the paperwork to the workers' comp insurance carrier, but the employee's doctor also needs to mail a medical report. Additionally, employers may need to submit documentation to the state workers' compensation board.

The PR-4 report is used for injuries pursuant to the 2005 edition of the Permanent Disability Rating Schedule (PDRS) in other words, you should choose the PR-4 report if the date of injury is on or after January 1, 2005.

The LES Form DWC-1, or First Report of Injury or Illness, is the form used to report workers' compensation accidents or work-related illnesses to your insurance carrier or designated claims office. Delays and errors may increase costs related to processing the claim.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232