The 48 Colorado forms that ask for a clinician's input, from workers' comp reports and FAMLI leave certifications to DMV, Medicaid, MOST and school care plans.
This page lists the 48 Colorado forms that ask for a clinician's input, grouped by program. On workers' comp claims the authorized treating physician files the WC164 Physician's Report at the first visit, when restrictions change and at MMI. FAMLI leave needs the Serious Health Condition Form. DMV uses the DR 2219 for disability parking and the DR 2401 and DR 2402 for medical and eye reports on drivers. Health First Colorado requests go on the Outpatient Prior Authorization Request Form and the pharmacy Prior Authorization Form.
Many of these forms are online. Providers registered in My FAMLI+ certify FAMLI claims there, outpatient Medicaid PARs go through the Acentra Health Atrezzo portal, and medical marijuana certifications are entered in the registry after an in-person visit. School allergy and asthma care plans are valid for one school year. Copies, scans and faxes of the MOST are as valid as the original. 5 forms here have a Spanish version, including the school immunization exemption certificates.
Authorized treating physician's initial, progress and closing report: diagnosis, work status/restrictions, treatment plan, MMI date and permanent impairment.
Requests insurer prior authorization for treatment, especially treatment outside the Medical Treatment Guidelines.
Notifies the insurer of prescribed treatment that the provider certifies is consistent with the Medical Treatment Guidelines (so it may proceed without prior authorization unless contested).
Therapist's structured progress note on improvement, compliance, objective measurements and functional scoring for the treating physician and insurer.
Worksheet for computing binaural hearing impairment for a permanent impairment rating.
Worksheets for rating lower extremity impairment (Part 1: toes, optional; Part 2: hip, knee and ankle).
Summarizes specific-disorder and range-of-motion spine impairment (with optional apportionment) for the final spine rating.
Worksheets for rating upper extremity impairment (Part 1: digits; Part 2: shoulder, elbow and wrist) under the AMA Guides 3rd ed. (revised) as adopted in Colorado.
Worksheet for computing visual system impairment for a permanent impairment rating.
Discloses ownership interests and employment relationships of an employer-designated health care provider on request.
Division IME examiner's one-page summary of findings on MMI date and impairment ratings.
DIME physician's disclosure of business, financial, employment or advisory relationships with the insurer/self-insured employer, provided on a party's request.
Required structure for the Division IME physician's report on maximum medical improvement and permanent impairment.
Worksheet for assigning a permanent mental/behavioral impairment rating under Colorado rules.
Certifies the claimant's or family member's serious health condition and the leave duration and absence parameter (7-day or 30-day limit) for Colorado FAMLI medical or care leave.
Health care provider certification for an employer's Unum-insured private plan under Colorado Family and Medical Leave Insurance (FAMLI).
Documents a newborn's admission to a neonatal unit or higher level of care so a parent can take Colorado FAMLI Neonatal Care Leave (from January 1, 2026).
CO PML Claim PacketHealth care provider certifies the employee's own serious health condition (including pregnancy) for Colorado FAMLI benefits under a Guardian private plan.
Physician's or APRN's assessment of conditions and degree of impairment relative to the driving task, used by the DMV to decide licensing, restrictions or re-evaluation.
Eye examination report on visual fitness to operate a motor vehicle, for licensing or medical re-evaluation.
Eye doctor's statement of a recent eye exam so a driver aged 80+ can renew their license online.
Applies for disability license plates or a permanent or short-term (temporary) placard, with written verification of the qualifying disability by a medical professional.
Health First Colorado prior authorization request (PAR) for outpatient services, DME, therapies and home health reviewed by Acentra Health.
General pharmacy prior authorization request for Health First Colorado fee-for-service outpatient drugs.
Certifies medical necessity (testing, flow rate, duration) for home oxygen under Health First Colorado.
Treating provider verifies why the member cannot be seen by a provider within 25 miles so long-distance NEMT can be authorized.
Licensed medical professional certifies the client's medical necessity as part of the long-term care functional assessment (nursing facility, ICF/IID or hospital level of care) for LTSS/HCBS eligibility.
Treating physician attests that a child has a life-limiting illness for enrollment in the Children with Life Limiting Illness (CLLI) waiver (10 CCR 2505-10 8.504.4.A.3).
Certificado de Exención Médica
Certifies a medical condition that prevents a student from receiving one or more school-required vaccines (permanent or temporary until a set date).
Certificado de Exención No Médica
Religious or personal-belief exemption from school-required vaccines, obtained either through CDPHE's online education module or with a signing health care provider who gives immunization consultation.
Diabetes provider medication orders for school (insulin by injection/oral agents, or insulin pump) that accompany the Colorado diabetes Individualized Health Plan.
Statewide standard allergy/anaphylaxis emergency plan and epinephrine medication order for schools, effective for one school year (C.R.S. 22-1-119.5).
Statewide school/child care asthma care plan that doubles as the provider's medication order for quick-relief inhaler use and self-carry.
Individual medical seizure action plan used by Colorado schools under HB21-1133 (K-12 seizure training and individual action plans) and 1 CCR 301-112.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Portable medical order for CPR, level of medical intervention and artificially administered nutrition for adults with chronic or serious illness.
Required report from the attending/prescribing provider documenting compliance with the Colorado End-of-Life Options Act when medical aid-in-dying medication is prescribed.
Places a person on an emergency mental health hold (up to 72 hours) under C.R.S. 27-65-106 when they appear to be a danger to self or others or gravely disabled due to a mental health disorder.
Documents the comprehensive evaluation of a person on an emergency or court-ordered hold to decide release, voluntary treatment or certification for short-term treatment.
Certifies a person for up to 3 months of short-term involuntary mental health treatment after evaluation, notifying the court and respondent.
Recommending provider certifies a debilitating (MD/DO only) or disabling medical condition and, per HB21-1317, records THC potency, directions, product and any above-limit daily quantity, supporting the patient's registry ID card application.
Formulario de certificación uniforme (Marihuana Medicinal)
Recommending provider authorizes a patient to purchase more than the statutory daily medical marijuana sales limit.
Provider report of a reportable communicable disease or condition (other than STIs/HIV, chickenpox and animal bites).
Provider report of a human animal bite or rabies exposure, with animal status and vaccination details, for rabies follow-up.
Provider case report of syphilis with stage, treatment and pregnancy information.
Medical professional certifies that medical care or incapacitation prevented the owner from renewing vehicle registration on time, so the late fee can be waived.
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 and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
WCRP Rule 16 calls for the authorized treating physician's WC164 at the initial visit, whenever work restrictions change, and at MMI as the closing report. It records the diagnosis, work status and restrictions, treatment plan, MMI date and any permanent impairment. Send it to the insurer with a copy to the injured worker. Impairment ratings are done by a Level II accredited physician using the Division's rating worksheets.
A provider registered in My FAMLI+ can certify the Serious Health Condition Form entirely online, after verifying their license, and can delegate staff. Otherwise the claimant prints the form from within the claim, has the provider sign it, and uploads a scan. There is no blank PDF. The provider chooses a 7-day or 30-day absence parameter limit. Employees on a private plan use the insurer's form instead, such as Unum's CL-1334-CO.
A physician, including commissioned medical officers of the US Armed Forces, USPHS or VA, an advanced practice nurse, a physician assistant or a podiatrist. Chiropractors may certify for a short-term placard only. The medical professional completes the verification section, and the applicant submits the form to the county motor vehicle office. The same form covers disability plates and permanent or short-term placards.
A Colorado MD or DO with an unrestricted DEA registration can certify any qualifying condition. Dentists, PAs, APRNs, podiatrists and optometrists with prescriptive authority can certify disabling conditions only, such as PTSD or autism spectrum disorder. The certification is entered online in the Medical Marijuana Registry after an in-person visit; telemedicine is not allowed. Minors need certifications from two different providers. To authorize more than the daily sales limit, use the DR 8560.