Commission-approved questionnaire the employer/insurer may send to treating providers about diagnosis, causation, work status, restrictions and MMI on an admitted claim.
- Completed by
- Treating medical provider
- Format
- Fillable PDF
- Language
- English
North Carolina workers' comp forms from the Industrial Commission
The Industrial Commission's preauthorization request, permanent impairment rating and Medical Status Questionnaire, and the physician statements on Forms 18M and 28U.
North Carolina's workers' comp forms come from the North Carolina Industrial Commission (NCIC). The Request for Preauthorization of Medical Treatment (Form 25PR) covers surgery and inpatient admission. The Evaluation for Permanent Impairment (Form 25R) rates permanent partial impairment by body part, and the form states that its use is required under the Workers' Compensation Act. The Workers' Compensation Medical Status Questionnaire asks about diagnosis, causation, work status, restrictions and MMI on an admitted claim.
The employer or insurer sends the questionnaire, and you answer only the items it checks, or reply in your notes or a narrative. The answers go to the employer or insurer and to the employee at the same time, and the employer or insurer must pay a reasonable fee up to the fee schedule amount for CPT 99080. Forms 18M and 28U are employee filings with a treating physician's statement. Vero Documents fills PDF forms from the visit note and the chart, and you review and sign.
Physicians, NPs and PAs
Requests insurer preauthorization of surgery or inpatient admission, with an appeal page if the initial request is denied.
- Completed by
- Requesting health care provider
- Format
- Fillable PDF
- Language
- English
Physician's rating of permanent partial impairment by body part (including amputation levels) for scheduled-loss compensation.
- Completed by
- Treating or rating physician
- Format
- Fillable PDF
- Language
- English
Employee applies for additional medical compensation after the claim closed; an optional treating physician statement supports the need for further treatment.
- Completed by
- Treating physician (optional Section B), plus the employee
- Format
- Fillable PDF
- Language
- English
Employee asks to reinstate disability compensation after a failed trial return to work, supported by the treating physician's statement that the employee could not continue working.
- Completed by
- Authorized treating physician (statement), plus the employee
- Format
- Fillable PDF
- Language
- English
More US forms
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Frequently asked questions
Do I need the patient's authorization to answer the NC Medical Status Questionnaire?
No. G.S. 97-25.6 lets the employer or insurer send the Commission-approved questionnaire without employee authorization. Answer only the items the employer checks, or reply in your notes or a narrative report. Responses go simultaneously to the employer or insurer (or rehabilitation professional) and to the employee or representative. You may charge a reasonable fee up to the NCIC fee schedule amount for CPT 99080.
How do I send a Form 25PR?
Send it to the insurer at the email or fax listed in the insurer's preauthorization review policy, with a copy to the employee or the employee's attorney. Page 1 is the request for surgery or inpatient admission, and page 2 is the provider's appeal if the initial request is denied. Determinations follow G.S. 97-25.3, and the insurer sends them to all interested medical providers.
Where does the Form 25R go?
The physician returns the Evaluation for Permanent Impairment to the insurance carrier, and the carrier files it through the Commission's Electronic Document Filing Portal. The treating or rating physician rates permanent partial impairment by body part, including amputation levels, for scheduled-loss compensation, following the NCIC Rating Guide, and signs the form.
What is the physician's part of Form 28U?
Item 3, the Treating Physician's Statement. When a trial return to work fails, the authorized treating physician states that the employee could not continue working, then signs and prints their name. The employee must get this statement before filing. Form 18M works the same way for additional medical compensation after a claim has closed, with an optional Treating Physician's Statement in Section B.