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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

Social Security Number: ________ - _______ - _________ Date of Injury: ______/______/____________ PA BWC Claim Number: ____________________________
(ifknown)
mm dd yyyy

Employee
First Name _________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town County __________________________________________ State Telephone (_______) _______ - _______________ Zip Code ________________________________________________ _________ ____________-_________ Last Name _____________________________________________

Employer
Name _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town County ____________________________________________ Telephone (_______)_______-____________________________ FEIN _____________________ State Zip Code ________________________________________________ _________ ____________-_________

Insurer or Third Party Administrator (if self-insured) COMPENSABLE INJURY:
Name _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town Telephone (_______) _______-___________________________ County State Zip Code Bureau Code _____________________ ________________________________________________ _________ ____________-_________

766 0308
DATE OF THIS NOTICE:
mm dd yyyy

______/______/___________

____________________________________________ Claim Number ____________________________________________ FEIN _____________________

Attorney for Employee (if known)
Name _________________________________________________________________________________ Firm Name _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town Telephone (_______)_______-____________________________ State Zip Code ________________________________________________ _________ ____________-_________ PA Attorney ID Number ________________________________

Attorney for Insurer/Employer (if known)
Name _________________________________________________________________________________ Firm Name _________________________________________________________________________________ Street 1 _________________________________________________________________________________ Street 2 _________________________________________________________________________________ City/Town Telephone (_______)_______-____________________________ State Zip Code ________________________________________________ _________ ____________-_________ PA Attorney ID Number ________________________________

Claim Representative SEE IMPORTANT INFORMATION ON REVERSE.
First Name _________________________________ Telephone (_______) _______ - _______________ Last Name _____________________________________________

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LIBC-766 REV 3-08 (Page 1)

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 _________________________________ Signature

Last Name _____________________________________________

_________________________________________________________________________________

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)