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E-mail This PageDOL Form LS-1
| 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: | 1240-0029 |
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