Workers' Compensation Forms Library
Employee Claim Form:
This form should be filed Within two years of accident, or within two years after employee knew or should have known that injury or illness was related to employment.
C-3 Doctor's Initial Report:
This form is filed within 48 hours of first treatment.
C-4 Doctor's Progress Report:
This form is used for the 15 day report after first treatment, and for each follow-up visit scheduled when medically necessary while treatment continues but not more than 90 days apart.
C-4.2 Doctor's Report of MMI/Permanent Impairment:
Use this form (1) When rendering an opinion on MMI and/or permanent impairment; or (2) In response to a request by the Workers' Compensation Board to render a decision on MMI and/or permanent impairment.
C-4.3 Attending Doctor's Request for Authorization and Carrier's Response:
This form is used to confirm a telephone request for written authorization for special service(s) costing over $1,000 in a non-emergency situation.
C-4Auth Work Search Form:
This form is to assist you in an independent job search. List all the employers, employment agencies and labor unions you have contacted while receiving workers' compensation benefits.
C-258 Medical and Travel Expense Request for Reimbursement:
As needed. Include copies of all receipts and bills, if possible.
C-257 Claimant's Authorization to Disclose Health Information:
HIPAA-1 Attending Doctor's Request for Optional Prior Approval and Carrier's/Employer's Response:
Request confirmation from the Insurance Carrier that the procedure or test is based on a correct application of the Medical Treatment Guidelines.
MG-1 Continuation to Form MG-1:
Request confirmation from the Insurance Carrier that more than one procedure or test is based on a correct application of the Medical Treatment Guidelines.
MG-1.1 Attending Doctor's Request for Approval of Variance and Carrier's/Employer's Response:
To request testing or treatment that is outside or exceeds the Medical Treatment Guidelines.
MG-2 Continuation of Form MG-2:
To request more than one test or treatment that is outside or exceeds the Medical Treatment Guidelines.
MG-2.1 Claimant's Authorization to Disclose Workers' Compensation Records:
Claimant must submit form with original signature in order to allow release of his/her records to parties not otherwise authorized to receive them.
OC-110A Loss of Wage Earning Capacity Vocational Data Form:
Injured Workers who may have a non-schedule permanent impairment and who have not returned to work are encouraged to complete and submit Form VDF-1 as early as possible in the claim.
Workers' Compensation Attorneys