Get Ut Form 123 2019-2026

The UT Form 123 is a critical document for reporting work injuries or occupational diseases. This guide will provide comprehensive, step-by-step instructions on how to accurately complete the form online, ensuring that all necessary information is properly submitted.

Follow the steps to accurately complete the UT Form 123 online.

1. Click the ‘Get Form’ button to access and open the UT Form 123 in your chosen editor.
2. In the 'Physician' section, enter the physician's name, phone number, treatment facility, and registered email address. Ensure the information is accurate, as it will be used for communication and correspondence.
3. Next, locate the 'Claim Number,' 'Policy Number,' and 'Class Code' fields. These are usually pre-filled by the insurance carrier, but confirm the details for correctness.
4. Under the 'Carrier' section, specify the insurance company’s name and mailing address, including the city and zip code. Accurate details here are crucial for proper documentation.
5. In the 'Patient' section, carefully fill out the employee's first name, middle initial, and last name. Also, provide their social security number, date of birth in MM/DD/YYYY format, gender, and telephone number.
6. Proceed to the 'Employer' section by including the name and address of the employer along with their telephone number. This information helps in identifying the workplace.
7. In the 'History' section, record the date of the injury, including the hour and AM/PM designation. Additionally, document the last date the employee worked and their statement of the cause of injury or illness in the first person.
8. Move on to the 'Examination' section. Clearly outline the diagnosis related to the industrial claim, including the corresponding ICD code.
9. Answer the question regarding whether the condition requiring treatment is a result of the injury or exposure. Select from 'Yes,' 'No,' or 'Undetermined.'
10. Indicate if the claimant requires an interpreter and specify the language if applicable.
11. Use the 'Comments' section to add any additional notes or information relevant to the claim.
12. Finally, input the date the form is submitted. Once all necessary fields are completed, save your changes. You can also print or share the form as needed.

Complete your UT Form 123 online today to ensure timely processing of your work injury claim.