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View ESA-OWCP-DLHWC's Form 1215-0066 Online 
| Agency: |
ESA-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 |
| OMB Expiration Date: |
Wednesday, December 31, 2008
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