In Kentucky workers' compensation, the employee chooses a designated physician who coordinates all care for the work injury and refers to other providers as needed. This two-sided form records that choice, the physician's acceptance, the employee's release of work-related medical information, and the medical payment obligor. It must reach the obligor within 10 days after treatment begins.
The employee completes and signs the form, including the medical information release. The designated physician signs the acceptance under the First Designated Physician block.
Download the current version from the source each time; forms change without notice.
Notice of Designated Physician
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Yes. The notice on Form 113 says the employee may choose the physician who treats them, including chiropractors, as designated physician. That physician coordinates the employee's medical care and may refer to consulting or treating physicians as required.
No. The form states it is not advance authorization from the workers' compensation medical payment obligor for medical services. It only identifies the designated physician, records the physician's acceptance and the employee's medical information release, and names the obligor's representative for inquiries.