Workers' comp, DMV medical review, parking, Medicaid drug PA, child care, sports, immunization exemption, POST and DNR forms from West Virginia agencies.
West Virginia's clinician forms come from the Offices of the Insurance Commissioner (OIC), the Division of Motor Vehicles, the Bureau for Medical Services and the West Virginia Center for End-of-Life Care. On workers' comp claims, practices see the OIC-WC-1 report of injury and the Attending Physician Benefits Form. The DMV sends the Medical Report Form (DLAB-1) and the vision specialist's DLAB-2, and the DMV-41-TR covers mobility impaired parking. Medicaid prescribers use the General Drug Prior Authorization Form. This hub lists 27 forms.
Workers' comp forms go to the private carrier, self-insured employer or TPA handling the claim. Medicaid pharmacy is carved out of managed care, so the general drug PA covers every member. WV POST and the orange DNR card are not online: clinicians get them from the Center, and patients are encouraged to file them with the e-Directive Registry. Medical exemptions from school vaccines go to the State Immunization Officer. Vero Documents fills PDF forms from the visit note and the chart, and the clinician reviews and signs.
Attending physician certifies the estimated period of temporary total disability, return-to-work date, MMI and readiness for a PPD rating so TTD benefits can be paid.
Claim application combining the employee's report of injury with the initial health care provider's report of diagnosis, body parts, causation and work status.
Prescriber questionnaire justifying continued opioid/controlled-substance therapy (pain diagnosis, history, prior treatments, tapering attempts, objective findings, risk discussion).
Lets the physician of record add or update ICD-10-CM diagnoses on a claim, with the clinical findings and relationship to the compensable injury.
Claimant's petition to reopen a claim for further PPD evaluation, with the treating physician's detailed findings on aggravation or progression.
Structured lumbar-spine examination used for claim reopening, impairment rating, 120-day, consultation, independent or comprehensive exams.
Occupational hearing-loss claim with audiometric results and the ENT's exam, diagnosis and causation findings.
Physician's report of history, examination, X-ray and pulmonary function findings and opinion on whether the claimant has occupational pneumoconiosis.
DLAB-1Examining physician reports history and details of diabetes, cardiovascular, neurological, mental illness, alcohol/drug and musculoskeletal conditions for a driver referred to DMV medical review.
Eye specialist records uncorrected/best-corrected acuity, horizontal fields and color vision and gives an opinion on safe driving (including commercial).
DLAB-CDL-1Commercial-driver version of the WV medical report (adds sleep disorder); diabetes section must be completed by a board certified/eligible endocrinologist.
Physician certifies a physical disability that prevents safe use of a safety belt (WV Code 17C-15-49(b)), permanent or for a stated period, and any alternate restraint.
Licensed physician certifies a permanent or temporary (up to 6 months) mobility impairment for a WV mobility impaired placard and/or plate.
Licensed physician certifies a permanent or temporary mobility impairment for a disabled veteran's mobility impaired plate (after WV Department of Veterans Assistance certification).
General West Virginia Medicaid pharmacy prior authorization request for drugs needing PA where no drug-specific form applies.
ECE-CC-3Health assessment required for children enrolled in West Virginia licensed child care (a HealthCheck exam report may be attached instead).
ECE-CC-3CMedical history and examination report for child care providers showing they can safely care for children.
Annual health history and physical examination required for WVSSAC athletic participation, packaged with concussion and sudden cardiac arrest information.
Physician request to the State Immunization Officer for a permanent or temporary (max 24 months) medical exemption from West Virginia school/child care vaccines, with supporting medical evidence.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Portable medical order for CPR, scope of treatment and nutrition honored by all health care professionals including EMS (W. Va. Code 16-30-25).
Out-of-hospital DNR order issued on an orange card, honored by EMS and other providers.
Registered physician certifies that a patient has a serious medical condition and specifies the form and allotment of medical cannabis, so the patient can apply for an ID card.
Online report of suspected child abuse or neglect to Centralized Intake.
Provider report of a reportable disease case to the local health department.
Mandatory reporter's written follow-up report of suspected abuse, neglect or financial exploitation of an incapacitated adult or facility resident (WV Code 9-6-11).
Physician, psychiatrist or psychologist certifies a communication disability so DMV can flag the driver/ID record for law enforcement.
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.
From the West Virginia Center for End-of-Life Care. There is no blank form online: clinicians obtain the forms from the Center, which does not mail them to patients. An MD, DO, APRN or PA completes the orders with the patient, MPOA representative or surrogate. The patient keeps it and is encouraged to submit it to the WV e-Directive Registry. Older versions remain valid, and the out-of-hospital DNR order comes on a separate orange card.
With the Request for Medical Exemption from Compulsory Immunization. A licensed physician who has treated or examined the child lists the vaccines, explains the contraindication or precaution, marks it permanent or temporary (up to 24 months, with a re-evaluation date) and attaches medical evidence. The physician files it by mail, email, fax or through WVSIIS, the State Immunization Officer approves or denies it, and the physician tells the parent the outcome.
The DLAB-2, Vision Specialist's Exam Results and Certification. A U.S.-licensed ophthalmologist or optometrist records uncorrected and best-corrected acuity, horizontal fields and color vision and gives an opinion on safe driving, including commercial driving. The patient signs in the specialist's presence, and the form goes back to the DMV. It is not for drivers using bioptic lenses. Other conditions go on the DLAB-1 Medical Report Form, based on an exam within 90 days.
The prescriber faxes it to the Rational Drug Therapy Program at the WVU School of Pharmacy, which handles pharmacy prior authorization for the Bureau for Medical Services. Use it for drugs that need PA when no drug-specific form applies. West Virginia carves pharmacy out of managed care, so this form covers all Medicaid members. Medical service prior authorizations go through Acentra Health instead.