In Vermont workers' compensation, medical case management services can be requested in advance on this form, under 21 V.S.A. §§601(31)(C) and 640b. Either the injured worker or a medical provider files it with the adjuster, attaching a health care provider's recommendation or other evidence that recovery would benefit from the services. The insurer must approve, deny or order an IME or records review within 14 days.
The requesting party, either the injured worker or a named medical provider with license number, completes and signs the request. A health care provider's recommendation is attached as support, and the adjuster completes the insurer action block.
Download the current version from the source each time; forms change without notice.
Request for Preauthorization of Medical Case Management Services from Injured Worker or Medical Provider
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.
Yes. The requesting party can be the injured worker or a medical provider, who enters name, license number and address and signs. Even when the worker files, the request is supported by a health care provider's recommendation or other evidence that the worker's medical recovery would benefit from case management.
Fourteen days from receiving the request. Within that time the adjuster approves, denies with a Form 2 and supporting evidence, or schedules an IME or records review; in that case a further response is due no later than 45 days from receipt of the request.