Under the Longshore and Harbor Workers' Compensation Act and its extensions, the employer uses this form to authorize a physician of the injured employee's choice to examine and treat a work injury or illness. The physician completes the initial report on page 2, covering history, findings, diagnosis, causation, hospitalization, surgery, disability periods and return-to-work dates, and sends it within 10 days.
The employer completes Part A, the authorization, and gives the physician the original and two copies. The physician chosen by the employee completes Part B, items 14 to 37.
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Request for Examination and/or Treatment
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Within 10 days. Part B tells the physician to send the original initial report to OWCP and a copy, with charges on a standard billing form, to the insurance company or employer listed in item 13. Later reports go on LS-204 or in narrative form while the employee remains in your care.
If the employer marks box B in item 7, you may examine the employee using non-surgical diagnostic studies and should promptly tell those listed in item 13 whether you believe the disability is due to the injury. Pending further advice, you may provide necessary conservative treatment.
The Longshore and Harbor Workers' Compensation Act and three extensions: the Defense Base Act, the Nonappropriated Fund Instrumentalities Act and the Outer Continental Shelf Lands Act. The employer marks the applicable act in item 1 when completing the authorization.