Get Form 113

Filling out the Form 113 is essential for designating a physician in relation to a workplace injury or occupational disease. This guide will provide you with clear instructions to complete the form accurately and efficiently online.

Follow the steps to fill out Form 113 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your information in the Employee section. Provide your full name, street address, city, state, zip code, date of birth, telephone number, and social security number.
3. In the Employer section, fill in the name, street address, city, state, and zip code of the employer at the time of the injury or last exposure.
4. Detail the nature of the injury or occupational disease, along with the date of injury or last exposure in the designated fields.
5. Provide information for the First Designated Physician section. Include the full name, street address, city, state, zip code, and telephone number of the physician you are choosing.
6. In the Medical Information Release section, review the waiver statement and ensure you understand your rights regarding the release of medical information. Sign and date the form where indicated.
7. Finally, review all completed sections for accuracy. Once verified, you can save your changes, download the completed form, print it, or share it as needed.

Complete your Form 113 online today for a smooth designation process.