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.

VDF-1