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Workers' Compensation Form Kentucky

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COMMONWEALTH OF KENTUCKY
OFFICE OF WORKERS' CLAIMS

Form 113

Designation of Physician

Revised 03-12-03

Two-Sided Form

Claim No.

NOTICE OF DESIGNATED PHYSICIAN

EMPLOYEE:

() - Telephone Number

Date of Birth

Social Security Number

EMPLOYER AT TIME OF INJURY OR LAST EXPOSURE:

NATURE OF INJURY OR OCCUPATIONAL DISEASE:

DATE OF INJURY OR LAST EXPOSURE:

FIRST DESIGNATED PHYSICIAN:

() - Telephone Number

Accepted by:

MEDICAL INFORMATION RELEASE:

I hereby waive any privilege I may have to restrict the release of information or written material reasonably related to the work-related injury/disease for which I have sought treatment, and I consent to the release of this information or written material to the medical payment obligor, my employer, Special Fund, Uninsured Employers' Fund, or attorneys representing me or any of the parties named above.

Date

Employee Signature

MEDICAL PAYMENT OBLIGOR:

() - Telephone Number

This form identifies the designated physician and must be returned to the medical payment obligor within ten (10) days after treatment begins. An identification card will be provided to the employee, and that card should be presented when medical treatment is required.

Notice: The Workers' Compensation Act requires the employer to pay for the medical services reasonably necessary for cure and relief from the effects of a workplace injury or disease.

The employee may choose the physician (including chiropractors, etc.) who treats him as “designated physician." The designated physician is responsible for the coordination of the employee's medical care and may refer the patient to consulting or treating physicians as required. Except in an emergency, all treatment must be performed by or on referral from the designated physician. The employee may not change his designated physician more than once without the medical payment obligor's consent.

Inquiries shall be made to the listed representative of the medical payment obligor.

This form is not advance authorization from the workers' compensation medical payment obligor for medical services.

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What the Workers' Compensation Form Kentucky Is and When It Applies

The Workers' Compensation Form Kentucky is the state-specific claim and reporting form used to record workplace injuries, initiate benefits, and document employer notice and insurer reporting obligations under Kentucky law. Employers, insurers, and injured workers use this form to capture accident details, medical treatment, wage information, and return-to-work status. The form supports claims processing, benefits calculation, and compliance with Kentucky Department of Workers' Claims requirements. It can be completed on paper or electronically; when submitted electronically, the form must meet ESIGN and UETA requirements for enforceability in intrastate and interstate transactions.

Why Accurate Completion Matters for Claims and Compliance

A properly completed Workers' Compensation Form Kentucky establishes the factual record for injury claims, accelerates benefit delivery, reduces processing errors, and documents employer compliance. Accurate forms minimize dispute risk, help calculate wage loss and medical benefits, and support timely insurer adjudication.

Why Accurate Completion Matters for Claims and Compliance

Who Completes and Relies on This Form

Employers, HR staff, claims adjusters, treating medical providers, and injured workers use the Workers' Compensation Form Kentucky to record incidents and support claims processing.

  • Employers and HR: prepare initial report, provide employer contact and wage verification.
  • Claims adjusters: review incident details, assign claim numbers, and coordinate benefits.
  • Medical providers: document injuries, treatment dates, diagnoses, and return-to-work status.

Step-by-Step: Completing and Submitting the Kentucky Workers' Comp Form

Follow these core steps to gather facts, complete fields, and deliver the form to the insurer and agency.

  • 01
    Collect Incident Facts: Obtain date, time, witness names, and immediate medical response.
  • 02
    Complete Required Fields: Enter worker, employer, and injury details per field guide.
  • 03
    Obtain Signatures: Worker, employer, and provider signatures as required.
  • 04
    Submit to Parties: Send to insurer and retain employer copy with audit trail.

Typical Digital Workflow Settings for Electronic Completion

Configure an eSubmission workflow that preserves identity evidence, audit trails, and copies for employer, insurer, and claimant.

Field Configuration
Signature Type Electronic signature with audit trail and timestamp
Authentication Email + SMS code recommended for signer attribution
Document Retention Immutable PDF with downloadable certificate
Recipient Routing Employer → Provider → Insurer in role-based order

How Electronic Submission Typically Works

A modern eSubmission flow streamlines signing, authentication, and delivery while preserving an audit trail acceptable under ESIGN and UETA.

  • Upload Document: Sender uploads the completed form and attachments.
  • Place Fields: Add signature, date, and text fields for each party.
  • Authenticate Signers: Use email links, SMS codes, or higher assurance where required.
  • Deliver Copies: Automatically send signed PDFs and audit certificates to all parties.

Platform and Integration Considerations for eSubmission

Ensure the eSignature platform supports secure PDF output, audit trails, and the integrations your organization uses.

  • File Formats: PDF and PDF/A output
  • Integrations: Connectors for HR/claims systems and cloud storage
  • Security: TLS in transit and AES-256 at rest

Security and Compliance Basics for Storing and Transmitting Forms

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest
Audit Trail: Timestamped events showing signer IP and actions
Certifications: SOC 2 Type II and ISO 27001 available
HIPAA: HIPAA-compliant workflows with BAA as required
eSign Laws: ESIGN Act and UETA legal acceptance
Accessibility: WCAG 2.0 Level AA support

Common Preparation Pitfalls to Avoid

  • Missing or inconsistent dates and times that create gaps in the incident timeline and delay adjudication.
  • Incomplete employer identification (EIN or legal name) that triggers requests for additional documentation.
  • Vague injury descriptions that require medical clarification and slow benefit approvals.
  • Unsigned or improperly signed forms that lead to rejected submissions or require re-execution.

Consequences of Errors or Late Reporting

Claim Denial: Incomplete information may result in initial denial or benefit delays
Delayed Payments: Missing treatment dates or provider details can stall payment
Premium Impact: Frequent or poorly documented claims can raise employer premiums
Regulatory Penalties: Late employer filing may trigger state administrative penalties
Fraud Investigation: Inaccurate submissions can prompt investigations and sanctions
Recordkeeping Risk: Failure to retain records jeopardizes defense in contested matters

Practical Tips for Accurate, Efficient Completion

Adopt consistent intake procedures and an electronic workflow to reduce errors and speed handling.

Collect Complete Incident Data
Capture witness names, exact incident location, time, and photos where safe; verify details with the injured employee before submission to reduce follow-up requests.
Standardize Field Entries
Use consistent formats for dates (MM/DD/YYYY), names, and addresses; templates and validation rules reduce free-text variance and downstream processing errors.
Validate Medical Provider Info
Confirm provider NPI or clinic address at intake to ensure claims route correctly and payments reach the correct provider without administrative delay.
Keep an Immutable Copy
Store a signed PDF with an audit certificate and export copies to employer, insurer, and injured worker to maintain a verifiable record.

Comparing eSignature Vendors for Workers' Compensation Workflows

A neutral comparison of common plan features and starting prices — signNow is listed first per vendor ordering rules; verify vendor plan details before purchase.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes Yes Yes Yes Yes
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No envelope cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Realistic Use Scenarios for the Kentucky Workers' Compensation Form

Two brief examples illustrate common workflows and documentation choices for workplace injuries in different settings.

Manufacturing Incident

A machinist sustains a hand laceration during a shift and reports immediately.

  • Employer documents witnesses and photos.
  • The completed form, provider report, and photos permit prompt authorization of treatment and minimize disputes during claim intake.

Healthcare Staff Injury

A nurse experiences a back strain while lifting a patient and seeks treatment the same day.

  • Employer logs incident and forwards to claims adjuster.
  • Detailed treatment records and return-to-work notes reduce administrative follow-up and support accurate benefit calculation.

Frequently Asked Questions About the Workers' Compensation Form Kentucky

Answers to common questions about eSigning, filing, signatures, and retention for Kentucky workers' compensation claims.


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