Form 123 Physician's Initial Report of Work Injury or Occupational Disease INSTRUCTIONS: 1) form to be completed by physician; 2) copy of completed form to be sent to insurance carrier with bill and progress reports; 3) copy of form only sent to injured employee, employee's employer, and Utah Labor Commission. This report must be filled pursuant to rule R612-100-3 (A), Utah Administrative Code. For your protection Utah law requires notification that any workers' compensation fraudulent claim for disability compensation on medical benefits is a crime and may be subject to fines and prison confinement. PLEASE PRINT OR TYPE 1. Physician Name 2. Physician Phone Number PHYSICIAN 3. Treatment Facility 4. Registered Email Do Not Use This Space CLAIM NO. POLICY NO. Class Code 5. Insurance Company CARRIER 6. Mailing Address City State Zip 7. Employee's First Name Middle Initial Last Name 8. SS # (or other) 9. DOB (MM/DD/YYYY) 10. Gender PATIENT 11. Mailing Address City State Zip 12. Employee Telephone Number 13. Name of Employer EMPLOYER 14. Address City State Zip 15. Employer Telephone Number 16. Date Injured (MM/DD/YYYY) Hour ______ ______ AM PM 17. Last Date Worked HISTORY _____________________________ 18. Employee's Statement of Cause of Injury or Illness (In First Person) 19. Diagnosis (Written Description as Related to Industrial Claim) w/ ICD Code EXAMINATION 20. Is the Condition Requiring Treatment the Result of the Industrial Injury or Exposure Described? Yes No Undetermined Yes No Language __________________ (If Answer is Yes) 21. Claimant Needs Interpreter 22. Other Comments COMMENTS 23. Date Submitted ___________________________ Official Form 123 Sta � Fax: Revised 10/14 State of Utah * Labor Commission * Division of Industrial Accidents 160 East 300 South * P O Box 146610 * Salt Lake City, UT 84114-6610 * Telephone: (801) 530-6800 FAX: 801-530-6804 * Toll Free: (800) 530-5090 * www.laborcommission.utah.gov American LegalNet, Inc. www.FormsWorkFlow.com