On an admitted North Carolina workers' compensation claim, the paying employer or insurer may send this Commission-approved questionnaire to providers who treated the employee. It covers diagnosis, causation, treatment plan, medications that impair work, return to the job described, hours, restrictions and permanent impairment at MMI, but only the questions the employer checks. Providers can answer on the form, in their notes, or in a letter.
The treating medical provider answers only the checked questions and signs, and need not answer questions without enough information to form an opinion. The employer or insurer fills in the patient and claim details, checks the questions, and may attach a job description.
Download the current version from the source each time; forms change without notice.
Workers' Compensation Medical Status Questionnaire
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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No. The instructions state that G.S. 97-25.6 authorizes medical providers to respond without an authorization from the employee. The questionnaire applies to admitted claims where the employer or insurer is paying compensation, and responses must go to the employee or the employee's representative at the same time as the employer or insurer.
Yes. Providers may charge a reasonable fee no higher than the current Industrial Commission fee schedule amount for CPT code 99080, and the requesting employer or insurer must pay it. The same applies whether answers are given on the form, in the medical notes, or in a letter.
Question 8 lists lifting, pushing and pulling, bending and stooping, kneeling and squatting, twisting, use of extremities, standing, walking, sitting, repetitive motions, driving, vibrations, climbing, and splints, crutches or bandages, with room for pounds and frequency. Question 7 limits hours per day and days per week.