Vermont Department of Labor forms clinicians complete on workers' comp claims: the HCP1 report, physical and cognitive work capabilities forms, and optional preauthorization requests.
The Vermont Department of Labor's Workers' Compensation Division publishes the forms treating providers use on Vermont claims. The Health Care Provider Report (HCP1) is the one the Division labels as a provider form. It covers complaints, diagnosis, work-relatedness, causal opinion, tests, the treatment plan, medications and work capacity. The Work Capabilities Form (Form 20) documents what the worker can do, such as standing, sitting, lifting, bending, reaching and hours, or total disability and how long it will last.
Send the HCP1 to the insurer or adjuster, with the state file number when you know it. The patient signs a release on Form 20 so it can go to the employer. Preauthorization is not required in Vermont, but Form P1 lets a provider ask for it, and the insurer must act within 14 days. Form P2 requests medical case management. The Cognitive Work Capabilities Form rates cognitive, self-regulation and resilience capacities on a 1 to 5 scale. All forms are in English.
Form 20Recommended form for medical providers to document an injured worker's physical work capabilities (stand, sit, lift, bend, reach, hours) or total disability and duration.
Treating provider's report of the work injury: complaints, diagnosis, work-relatedness, causal opinion, tests, treatment plan, medications and work capacity/restrictions.
Optional request by a health care provider for insurer preauthorization of proposed treatment, with medical-necessity letter and work-relatedness explanation (21 V.S.A. s.640b).
Requests insurer preauthorization of medical case management services, supported by a health care provider's recommendation (21 V.S.A. ss.601(31)(C), 640b).
Documents a patient's cognitive, self-regulation and resilience work capabilities on a 1-5 scale with suggested job modifications, for return to work and disability benefits.
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.
The Health Care Provider Report, the treating provider's report of the work injury. It records complaints, diagnosis, work-relatedness, causal opinion, tests, the treatment plan, medications and work capacity or restrictions. Send it to the workers' compensation insurer or adjuster, with the state file number when known. It is a fillable PDF from the Vermont Department of Labor's Workers' Compensation Division.
No. Form P1, Request to Insurance Company for Preauthorization of Medical Treatment, is optional. The provider attaches a medical-necessity letter and explains work-relatedness under 21 V.S.A. s.640b. The insurer must act within 14 days, or schedule an IME or records review and respond within 45 days. Set the proposed treatment date at least 14 days after the request.
The treating medical or psychiatric provider, and an occupational therapist, speech-language pathologist, neuropsychologist, psychologist or counselor may complete sections. The form rates cognitive, self-regulation and resilience work capabilities on a 1 to 5 scale and suggests job modifications. Give it to the employer, vocational rehabilitation counselor or insurer as needed. It can also support short-term disability, long-term disability and SSDI documentation.
The Work Capabilities Form is the Division's recommended form for documenting an injured worker's physical capacities: standing, sitting, lifting, bending, reaching and hours, or total disability and its expected duration. The treating provider completes everything except the patient release at the bottom. The patient signs that release so the form can go to the employer or insurer.