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Division of Workers' Compensation
 

Physician Reports/Worksheets/Disclosure

Form

Description

Physician's Reports

Form #WC164

Fillable  pdf MS Word


 

This form is used by the physician to provide information on the status, progress and medical treatment of the injured worker.  It is also used to provide information on the date of maximum medical improvement and permanent impairment.  A copy of the completed report is provided to both the insurer and the claimant.

Permanent Mental Impairment Rating Worksheet

Form # WC-M3 Psych

Fillable  pdf MS Word

 

This worksheet is used by Level II Accredited Physicians to assign permanent mental impairment ratings. 

Pharmacy Billing Statement

Form # WC-M4 Psych

Fillable  pdf MS Word


 

This form is used by the Pharmacy to bill the carrier for payment.

Designated Health Care Provider Disclosure Form

Form #WC030

Fillable  pdf MS Word

 

This form is used by a designated health care provider when a request is made for information on ownership interests and employment relationships.
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