Pennsylvania Bureau of Workers' Compensation forms clinicians complete, from the monthly LIBC-9 medical report to impairment rating and utilization review face sheets.
Pennsylvania's Bureau of Workers' Compensation, part of the Department of Labor & Industry, issues the forms providers use on work injury claims. The one you meet most is the LIBC-9, the Workers' Compensation Medical Report Form. It reports history, diagnosis, treatment, findings, prognosis and return-to-work restrictions, and it must go with your bills before the employer or insurer has to pay. Physicians also mark dismemberment charts for the hand (LIBC-134) and foot (LIBC-134F) and sign the Physician's Affidavit of Recovery (LIBC-497).
File the LIBC-9 with the employer or insurer within 10 days of starting treatment, then at least monthly while treatment continues. You may not charge for documentation that supports a bill, but the usual fee applies to special reports the employer or insurer requests. The LIBC-497 is sworn, so it needs a wet signature and a notary. Impairment rating physicians complete the LIBC-767 electronically in WCAIS. All forms here are in English.
Mandatory provider report (history, diagnosis, treatment, findings, prognosis and return-to-work restrictions) that must accompany bills before the employer/insurer must pay.
LIBC-134Physician-marked diagram of hand/finger amputation level for specific-loss benefits under Section 306(c).
LIBC-134FPhysician-marked diagram of foot/toe amputation level for specific-loss benefits under Section 306(c).
Sworn physician statement that the employee has fully recovered from the work injury and can resume the previous occupation without limitation, supporting termination of benefits.
Face sheet for an impairment rating evaluation (IRE) under Section 306(a.3), reporting the whole-person impairment percentage per the AMA Guides 6th edition.
Face sheet for a utilization review organization's determination on the reasonableness and necessity of a provider's treatment.
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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The treating provider files the LIBC-9 with the employer or insurer within 10 days of starting treatment, then at least monthly while treatment continues. It is required by 34 Pa. Code 127.203. The report covers history, diagnosis, treatment, findings, prognosis and return-to-work restrictions, and it must accompany your bills before the employer or insurer has to pay them.
Yes. The Physician's Affidavit of Recovery is a sworn statement, so it needs a wet signature and a notary. The examining physician states that the employee has fully recovered from the work injury and can resume the previous occupation without limitation. The affidavit goes back to the employer or insurer that requested it, for use before a workers' compensation judge.
A Bureau-designated IRE physician who is board-certified and licensed in Pennsylvania. The face sheet reports the whole-person impairment percentage under the AMA Guides 6th edition for an evaluation under Section 306(a.3). The physician completes it in WCAIS and sends copies of the report to the employee, attorney and insurer within 30 days of the evaluation, stating the charge on the form.
No. The Utilization Review Determination Face Sheet is completed by the utilization review organization, through a peer reviewer of the same profession as the provider under review. The treating provider supplies records. The URO mails the determination to all parties, and a party who disagrees may file the LIBC-603 before a workers' compensation judge. It is listed here for clinicians who work as reviewers.