Wisconsin state employees applying for Income Continuation Insurance need a physician to document their disability on this 2-page report under Wisconsin Statutes 40.61 and 40.62. The physician gives the diagnosis, objective findings, services since the last day worked, hospital stays and surgery, then answers whether the patient is totally disabled under the short-term definition and whether the disability is permanent for any occupation.
The claimant completes Section I, an authorization to release medical information, and the top of the back page. A physician completes and personally signs Section II; a podiatrist, dentist, NP, PA or psychologist may also complete it when acting under physician supervision.
Download the current version from the source each time; forms change without notice.
Income Continuation Insurance (ICI) Medical Report
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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A licensed medical doctor, doctor of osteopathy or surgeon, who must sign personally. A podiatrist, dentist, nurse practitioner, physician assistant or psychologist acting within their license may also complete it when supervised by a licensed physician; supervision isn't required for a DPM or DDS. The claimant cannot be the physician.
No. The instructions to the physician say to mail the completed and signed form directly to the Department of Employee Trust Funds and not to return it to the patient. The claimant's job is to complete Section I and bring the form to you promptly.