Workers' comp reports, DMV driver and placard forms, the SNAP work-capacity attestation, POLST and the other Nevada forms clinicians complete, with official links.
Nevada's forms come from the Division of Industrial Relations, the DMV, the Division of Social Services and the Department of Health and Human Services. Clinicians meet these most: the Employee's Claim for Compensation/Report of Initial Treatment (C-4), the progress report and certification of disability (D-39), the Disabled Persons License Plates and/or Placards Application (SP-27) and the Medical Provider ABAWD Attestation (2941-EF) for SNAP. This page lists all 21 Nevada forms, grouped by program.
The C-4 is shared: the employee completes the top half, and the treating provider completes the Report of Initial Treatment and mails it within 3 working days. The 2941-EF asks only about work capacity, not for a diagnosis or treatment records. The Confidential Physicians Report (DLD-007) must reach the DMV within 30 days of the exam. A Nevada POLST must be on the official pink form, ordered free from Nevada POLST. Spanish versions exist for 2 of these forms.
Combines the injured employee's claim for compensation with the treating provider's report of initial treatment (diagnosis, work status, causation and need for further care).
Progress report that certifies temporary total disability or release to full or restricted duty, with diagnosis, objective findings, ratability and treatment plan.
Asks the insurer to authorize additional chiropractic treatments beyond those already approved, with current findings and expected completion and return-to-work dates.
Asks the insurer to authorize additional physical therapy treatments, documenting present condition and number of further visits requested.
Records the periodic lung examination (chest X-ray, stethoscopic exam, spirometry) that police officers and firefighters must undergo to keep the lung-disease presumption under NRS 617.455.
Records the extensive heart examination (EKG, stress EKG at 40+, lipids, glucose) required for the heart-disease presumption under NRS 617.457.
Records the limited (interim) heart examination for police officers and firefighters under NAC chapter 617 and NRS 617.457.
Records audiometric results and otoscopic exam for police officers and firefighters for occupational hearing-loss purposes.
Clinician reports diagnosis, stability, medications, seizure/loss-of-consciousness history and recommended restrictions so the DMV can assess a motorist's ability to drive.
Records acuity with and without correction and any progressive eye disease for an applicant who failed the DMV vision screening.
Vision specialist reports telescopic and carrier-lens acuity and recommends restrictions for a driver who wants to drive with bioptic telescopes.
Physician certifies a medical need for darker window tint, the recommended visible light transmittance and whether the permit should be 4-year or indefinite.
Certifies a temporary (up to 6 months), moderate (up to 2 years) or permanent disability for disabled plates, placards or motorcycle/moped stickers.
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.
Actionable medical order for patients near the end of a life-limiting illness or very frail, honored in all settings.
Provider confirms the applicant's chronic or debilitating medical condition and sets the registration term (1 or 2 years) for a Nevada medical cannabis registry card.
Provider report of a Nevada reportable disease (incl. STDs, HIV/AIDS, animal bites) to the local health authority.
Report of suspected abuse, neglect, exploitation, isolation or abandonment of an older or vulnerable adult.
Licensed physician certification of a disability (NAC 503.1465) that prevents use of conventional archery equipment, for a permit to use a crossbow or draw-lock device.
Physician or eye doctor statement that a Nevada resident has a severe physical disability that materially limits gainful employment, or is blind, for a $15 specialty combination hunting and fishing license.
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.
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Two people. The employee completes the top half, the claim for compensation, which includes a medical release. The treating physician, chiropractic physician, PA-C or APRN completes the Report of Initial Treatment at the first visit: diagnosis, whether the patient is off work 5 or more days, full or modified duty, and job causation. The provider must complete and mail the report within 3 working days, with copies to the insurer or TPA, the employer and the employee.
It is the progress report after follow-up visits. The treating physician or chiropractic physician certifies temporary total disability or release to full or restricted duty, with diagnosis, objective findings, ratability and treatment plan. The one-page fillable PDF has restriction checkboxes and Stable/Ratable and Discharged boxes, which can trigger claim closure or a PPD rating. Send it to the insurer or TPA, and to the MCO if there is one.
A licensed physician, physician assistant, APRN, occupational therapist or physical therapist completes the certification on page 2. One form covers temporary (up to 6 months), moderate (up to 2 years) and permanent disability, for plates, placards or motorcycle and moped stickers. There is no fee for placards. Erasures or whiteout void the form. The applicant submits it at a DMV office or by mail; first-time plates require an office visit.
Whether a SNAP able-bodied adult without dependents can do 80 hours a month of work activities, whether the limitation is temporary or permanent, how long it will last, and a plain-language description of it. The form explicitly asks for no diagnosis or treatment records, only functional capacity. Any licensed medical professional can sign it. It comes in English and Spanish and goes back to the Division of Social Services.