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November 4, 2008    DOL Home > Find It! By Form > DOL Form   

DOL Form LS-204

View ESA-OWCP-DLHWC's Form 1215-0160 Online htm
Agency: ESA-OWCP-DLHWC
Title: DLHWC (Longshore) LS-204, Attending Physician's Supplementary Report
Form Description: DLHWC (Longshore) LS-204, Attending Physician's Supplementary Report: This form is submitted by the attending (treating) physician to submit supplemental progress reports relating to the injured employee's treatment for a work-related injury or occupational illness. This report is used to assist in determination entitlement to workers' compensation benefits.
OMB Control Number: 1215-0160
OMB Expiration Date: Monday, August 31, 2009




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