COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS’ COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (Toll Free) 800-482-2383 REQUEST FOR DESIGNATION OF A PHYSICIAN TO PERFORM AN IMPAIRMENT RATING EVALUATION Employee Social Security Number: ________ - _______ - _________ Date of Injury: ______/______/____________ mm            dd                  yyyy PA BWC Claim Number: ____________________________                                               (if known) Employer First Name Last Name Name _________________________________ _____________________________________________ _________________________________________________________________________________ Street 1 Street 1 _________________________________________________________________________________ _________________________________________________________________________________ Street 2 Street 2 _________________________________________________________________________________ _________________________________________________________________________________ City/Town City/Town State Zip Code State Zip Code ________________________________________________ _________ ____________-_________ ________________________________________________ _________ ____________-_________ County Telephone County __________________________________________ (_______) _______ - _______________ ____________________________________________ Telephone FEIN (_______)_______-____________________________ _____________________ Insurer or Third Party Administrator (if self-insured) COMPENSABLE INJURY: Name _________________________________________________________________________________ Street 1 766 0308 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town State Zip Code ________________________________________________ _________ ____________-_________ Bureau Code (_______) _______-___________________________ Date of this notice: Telephone _____________________ County ______/______/___________ mm      ____________________________________________ dd         yyyy Claim Number Attorney for Employee (if known) FEIN ____________________________________________ _____________________ Attorney for Insurer/Employer (if known) Name Name _________________________________________________________________________________ _________________________________________________________________________________ Firm Name Firm Name _________________________________________________________________________________ _________________________________________________________________________________ Street 1 Street 1 _________________________________________________________________________________ _________________________________________________________________________________ Street 2 Street 2 _________________________________________________________________________________ _________________________________________________________________________________ City/Town City/Town State Zip Code State Zip Code ________________________________________________ _________ ____________-_________ ________________________________________________ _________ ____________-_________ Telephone PA Attorney ID Number Telephone PA Attorney ID Number (_______)_______-____________________________ ________________________________ (_______)_______-____________________________ ________________________________ Claim Representative see important information on reverse. First Name Last Name _________________________________ _____________________________________________ Telephone (_______) _______ - _______________ (OVER) LIBC-766 REV 3-08 (Page 1) American LegalNet, Inc. www.FormsWorkflow.com The referenced Insurer/Employer requests the Bureau of Workers' Compensation to select a physician for an Impairment Evaluation to be conducted in accordance with Section 306(a.2) of the Workers' Compensation Act. Copies of this request have been served on all parties. First Name Last Name _________________________________ _____________________________________________ Signature _________________________________________________________________________________ Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994. Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-766 REV 3-08 (Page 2) American LegalNet, Inc. www.FormsWorkflow.com