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Nevada D-39 Physician Progress Report (Disability)

After the initial C-4 report, Nevada treating physicians and chiropractic physicians document follow-up visits on the D-39. The one-page report gives the diagnosis and its relation to the industrial injury, objective findings, whether the patient is stable, ratable or discharged, the treatment plan, and the work certification: full duty, temporarily totally disabled for stated dates, or restricted duty with permanent or temporary restrictions.

Who completes it

The treating physician or chiropractic physician completes and signs the whole form, including the date of this exam and the date of the next visit.

Submitting and payment

How to submit it
Send it to the insurer or third-party administrator after follow-up visits, and to the managed care organization if one is named on the claim.

Good to know

  • The Stable, Ratable and Discharged boxes are used to trigger claim closure or a permanent partial disability rating, so mark them carefully.
  • Certifying temporary total disability requires from and to dates; a restricted duty release needs dates and whether restrictions are permanent or temporary.
  • Restriction checkboxes cover sitting, standing, walking, bending at the waist, stooping, lifting, carrying, pushing, pulling, climbing and reaching above shoulders, with a pound limit for lifting.
  • The treatment plan can note PT or OT prescribed or discontinued, consultation, case management, further diagnostic studies, prescriptions, and whether medication may be used while working.

Get the official form

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

Physician's and Chiropractic Physician's Progress Report - Certification of Disability

Official pagePDF

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 and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

What does 'ratable' mean on the Nevada D-39?

The D-39 asks whether the patient is stable, whether the condition is ratable, and whether the patient may have suffered a permanent disability. These boxes are used to trigger claim closure or a permanent partial disability rating, so they should reflect the physician's current judgment at that visit.

Who can complete the D-39?

The treating physician or the treating chiropractic physician, as the title Physician's and Chiropractic Physician's Progress Report indicates. The form ends with the provider's name and signature, the date of the exam and the date of the next visit.

How is the D-39 different from the C-4?

The C-4 combines the employee's claim with the provider's report of initial treatment at the first visit. The D-39 is used for later visits to report progress and certify disability or work release, and it also asks about previous injuries contributing to the condition and the patient's job description.