U.S. DEPARTJ\.1ENT OF LABOR 

EMPLOYMENT STANDARDS ADM1N1STRATION 

Office of Workers' Compensation Programs 

September 16, 1977 

No. 35 

NOTICE TO INSURANCE CARRIERS, SELF-INSURED EMPLOYERS UNDER 

THE LONGSHOREMEN'S AND HARBOR WORKERS' COMPENSATION ACT, 

AS EXTENDED 

SUBJECT: Revised Definition of "Physician" under LHWCA, 

and Revised Form LS-1, Request for Examination 

and/or Treatment 

On September 9, 1977, a revised §702.404 of Title 20, Code of 

Federal Regulations, Part 702, was published as a Department of 

Labor regulation in the Federal Register. The revised paragraph 

states that the term "physician" as used under the Longshoremen's and Harbor Workers' Compensation Act {and its extensions) 

"includes doctors of medicine (MD), surgeons, podiatrists, 

dentists, clinical psychologists, optometrists and osteopathic 

practitioners within the scope of their practice as defined 

by State law. The term also includes chiropractors, but 

payment for their services will be limited to charges for 

physical examinations, related laboratory tests and x-rays 

made or required by a chiropractor to diagnose a subluxation 

of the spinal column, and treatment consisting of manual 

manipulation of the spine to correct a subluxation shown by 

x-ray. Physicians defined in this part may interpret their 

own x-rays. All physicians in these categories are authorized 

by the Director (OWCP) to render medical care under the Act. 

Naturopaths, faith healers and other practitioners of the healing 

arts which are not listed herein are not included within the 

term 'physician' as used in this part." 

Form LS-1 

Pursuant to the revised regulation, which enlarges the scope 

of choice available to an injured employee covered by the 

Act(sl, Form LS-1, Request for Examination and/or Treatment, 

has been revised. A copy of the revised form is attached to 

this notice. 

This form, which was originally introduced shortly after the 

enactment of Public Law 92-576, effective November 26, 1972, 

amending the Longshoremen's Act, was transmitted to all 
No. 35 - 2 -

insurance carriers authorized under the Act(s) by Notice 

No. 6, dated January 23, 1973. It has come to the attention 

of this Office that the form is not being utilized to the 

extent desired under this program, and this notice is issued 

to serve the dual purpose of announcing the changed 

regulation regarding "physicians" and of reminding insurance 

carriers and employers of the requirement that the form 

is to utilized in all cases of referrals of injured employees 

to physicians for medical care. Use of the form is 

essential to provide evidence that an employee was in fact 

permitted to choose his or her treating physician as 

envisioned under the amended Act. 

This is a two part form. Part A-Authorization, provides a 

convenient means for the employer of the injured employee 

to provide medical care as required under the Act by an 

authorized physician of the employee's choice. Part A is 

.to be completed in triplicate by the· employer and given to 

the employee to deliver to the authorized physician of choice. 

The physician is to complete Part B-Attending Physician's 

Report, and send one each to the deputy commissioner whose 

address is shown in item 12, and the insurance carrier or 

self-insured employer, retaining one copy. Instructions to 

the employer and the physician are printed on the front and 

back of the form. (Periodic medical reports, or as requested 

by the Office of Workers' Compensation Programs District 

Office, are to be submitted by the physician to OWCP on 

Form LS~204, revised February 1976, or in narrative form.) 

Instructions for distribution 

All insurance carriers authorized under the Act or its 

extensions who provide coverage to employers are responsible 

for providing an adequate supply of the form to all risks 

insured under one of the acts administered under the Longshore 

Program. Authorized self-insured employers must also maintain 

an adequate supply of forms to serve their needs. 

Insurance carriers and self-insured employers are authorized 

to print their own supplies of this form, provided they conform 

to the sample in all respects. The form may also be obtained 

from the Superintendent of Documents, Government Printing 

Office. washinoton, D.C. 40402, or from the three commercial 

printing companies authorized to print LHWCA forms. 
No. 35 - 3 -

A small supply of the form for temporary use may be obtained 

from the District Offices of the Office of Workers' Compensation Programs. 

~.!;o!~ 

Associate Director for 

Longshore and Harbor 

Workers' Compensation 

Attachment