DOL Form LS-1

View OWCP-DLHWC's Form LS-1 Online htm

Agency:

OWCP-DLHWC

Title:

DLHWC (Longshore) LS-1, Request for Examination and/or Treatment

Form Description:

DLHWC (Longshore) LS-1, Request for Examination and/or Treatment: This form is given to the injured worker by the employer/insurance carrier to authorize the injured worker to select and be treated by a physician of the injured worker's choice. It is a two-sided form; the employer/insurance carrier completes the front page and the selected attending physician completes the reverse side.

OMB Control Number:

1215-0066