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Office of the Assistant Secretary for Policy

DOL Form LS-1

View OWCP-DLHWC's Form LS-1 Online htm
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