Vermont's Workers' Compensation Division provides this one-page report for the treating provider to document a work injury at an initial or follow-up visit. It captures the patient's complaints, diagnosis, whether the condition is work related, the provider's objective opinion on causation, tests and results, treatment plan, medications and work capacity. The completed report goes to the workers' compensation insurer handling the claim.
The treating health care provider completes and signs the whole report. Patient details such as name, date of birth and employer at the time of injury come from intake; there is no separate patient or employer section.
Download the current version from the source each time; forms change without notice.
Health Care Provider Report
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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At any visit for a work injury, initial or follow-up; the form has a checkbox for each. Because it records the examination date, diagnosis, causation opinion, treatment plan and restrictions, a new HCP1 can document how those change over the course of the claim.
Yes. The medical information section says to attach additional sheets if necessary, and the footer has a yes or no box for narratives or test results attached. Attaching diagnostic results supports the tests and causation sections, which have limited space on the one-page form.