WorkplaceNL Form MD: Physician's Report and Code Sheet

Newfoundland and Labrador physicians complete this report for a new work-related injury, a possible recurrence of an earlier one, and progress visits when the worker's condition, treatment or return-to-work status changes significantly. Clinical details in Section B are entered as numeric codes from WorkplaceNL's code sheet. On the day of the visit you give the worker the employer's copy, which shows only the red-outlined sections, to deliver by the next working day.

Who completes it

The treating physician completes Sections A to E and signs the certification. The worker delivers the employer's copy, and workers and employers file their own injury reports (Forms 6 and 7).

How to fill it in

Section A - General Information

Print clearly: claim number; the worker's name, mailing address, phone, date of birth, MCP number, gender, occupation, employer and date of injury; and whether the injury developed over time without a specific incident. Add your name, address, phone and fax, WorkplaceNL billing number, whether a reporting fee is requested and MCP fee codes. Record the visit date and time (yyyy/mm/dd), whether you are the primary health care provider, whether you saw the worker in the office or emergency, and whether this is an initial report.

Section B - Specific Information for Parts of Body Injured

Box 6 takes the mechanism of injury, needed only on the initial report unless it changes or new information emerges. In box 7, code up to three parts of body with left, right or centre; if a part is not listed, use 90 (Other) and write it below. For each part, enter code-sheet codes for subjective reports, objective findings, diagnoses, treatments, investigations and assistive devices, one code per box. Progress reports add Update Status letters, A (resolution) to F (worsening). Answer whether the injury aggravated a prior health issue and whether other issues affect recovery.

Section B, box 8 - Additional Comments

Whenever you use an Other code (except for part of body), write the code number and the details here, for example '92 - negative bowstring test'. Record the details of decreased range of motion (code 10) here too, and explain any yes answer to the prior health issue or other issues questions. Remember that Investigations codes are only for referrals made at this visit.

Section C - Specific Information for All Diagnoses (Pertaining to Section B)

Question 9 asks whether WorkplaceNL should arrange a specialty appointment (interdisciplinary program, EMG/NCS, neurosurgeon or orthopaedic surgeon); attach a referral letter. Question 10 covers any other specialist referral, with name, specialty and appointment date if known. Question 11 asks whether you prescribed opioids at this visit. Question 12 lists medications added, discontinued or changed, with dose, frequency, quantity and repeats, but only those prescribed for the work injury.

Section D - Return-to-Work Status

In box 13, tick 'Worker has full functional abilities to return to work' and go to Section E, or tick and specify each restriction: lifting (under 10, 20 or 50 lbs, avoid repetitive, no lifting), bending/twisting, standing, climbing, kneeling/crouching, sitting, walking, upper extremity, medication-related restrictions, environmental limitations and other limitations. Box 14 sets recommended work hours (pre-injury or other) and whether to graduate them; box 15 estimates how long these abilities will last: 1 to 2, 3 to 7, 8 to 14, or 15+ days. The employer sees this section.

Section E - Follow-up

Box 16 records whether you reviewed the report with the worker, gave them a copy, and gave them the employer's copy to deliver. Box 17 asks whether a follow-up appointment is needed and when (1 to 7, 8 to 14, 15 to 21 or 22+ days), and whether you want WorkplaceNL to call you. In box 18, sign and date to certify that the report is complete and accurate and that you have received no prior payment from WorkplaceNL for this visit.

Common mistakes

Stamping your name, contact details or billing number; stamps do not transfer to the worker and employer copies, and the form is treated as illegible.
Incomplete or illegible reports, for which WorkplaceNL does not pay reporting fees; print clearly and complete every applicable box.
Using an Other code in Section B without writing the code number and details in Additional Comments (box 8).
Spreading a two-digit code across two boxes; use only one code box per code, whether it has one or two digits.
Coding investigations that were not referred at this visit; the Investigations category is only for referrals made at the time of the visit.
Listing medications for non-work conditions in question 12, which covers only medications prescribed for the work injury.

Submitting and payment

How to submit it: Fax the paper form to WorkplaceNL, since the instructions say it must be faxed only, or submit it online through connect, which needs a clinic connect account and earns a higher reporting fee.
Who pays: The form takes your WorkplaceNL billing number, MCP fee codes and whether a reporting fee is requested, and WorkplaceNL pays more for reports filed through connect than on paper but no reporting fee for incomplete or illegible reports.

Good to know

It is a triplicate form: white physician's copy, yellow employer's copy and blue worker's copy. Do not use stamps; stamped details do not reach the other copies and the form is deemed illegible.
Section B uses the MD, 8/10c and PR Code Sheet, effective September 2023. Range of motion percentage codes are for physiotherapy and chiropractic use only; decreased range of motion (code 10) is physician-only.
Recommending an assistive device may also require a Health Care Devices and Supplies Prescription form, and asking WorkplaceNL to arrange a specialty appointment requires an attached referral letter.
The posted PDF is a reference copy with instructions, a worked Section B example and the code sheets; it has no fillable fields.

Get the official form

Download the current version from the source each time; forms change without notice.

Physician's Report (Form MD)

Official page PDF

Fill it with Vero

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.

Sources for this guide

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Frequently asked questions

When do physicians complete WorkplaceNL Form MD?

For new injuries the physician or worker believes are work-related, possible recurrences of a previous work-related injury, and progress reporting when there is a significant change in the worker's condition, treatment or return-to-work status. Section A asks whether it is an initial report; on progress reports, add Update Status letters to the Section B subjective and objective codes.

What does the employer see on Form MD?

Only the red-outlined sections appear on the yellow employer's copy: identification details, the Section B body part codes, the Section D return-to-work status and most of Section E. The mechanism of injury, clinical codes and Section C medications are blacked out. The worker must deliver this copy by the next working day after your visit.

Can I use a stamp on WorkplaceNL Form MD?

No. WorkplaceNL asks physicians not to stamp any information, including name, contact details or billing number. Form MD is a triplicate, so stamped information does not appear on the worker and employer copies, and forms using stamps are considered illegible, which means the reporting fee is not paid. Print clearly instead.

Is the fee higher for filing Form MD online?

Yes. WorkplaceNL pays a higher fee for MD reports submitted online through connect than for paper reports. Your clinic needs a connect account to report online, and WorkplaceNL's physicians page explains how to register. Either way, enter your WorkplaceNL billing number and MCP fee codes, and tick whether a reporting fee is requested.