Get Form 113

Filling out Form 113 is essential for designating a physician for workplace-related injuries or diseases. This guide provides a step-by-step approach to efficiently complete the form online.

Follow the steps to accurately fill out Form 113

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. Begin by entering the claim number in the designated field at the top of the form. Ensure that this number is accurate to avoid processing delays.
3. Fill in your personal information under the 'Employee' section. Input your name, street address, city, state, zip code, date of birth, telephone number, and social security number.
4. In the employer section, write the name and address of the employer at the time of injury or last exposure. Include the city, state, and zip code.
5. Describe the nature of your injury or occupational disease. Be as specific as possible to ensure clarity regarding your medical needs.
6. Enter the date of injury or last exposure in the appropriate field to provide a timeline for the injury.
7. Indicate the first designated physician's name and address, including the city, state, and zip code. It is crucial to select a physician who is willing to take responsibility for your medical care.
8. Provide the telephone number for the designated physician to facilitate communication regarding your medical care.
9. Read the medical information release section carefully. Confirm your understanding and then provide the date and your signature to consent to the release of medical information.
10. Finally, complete the section for the medical payment obligor. Fill in the name, representative, address, and telephone number to finalize the document.
11. Once all sections are accurately filled, save your changes. You can also download, print, or share the form as required.

Complete your documents online for efficient processing.