West Virginia Offices of the Insurance Commissioner forms physicians complete on workers' comp claims, from the OIC-WC-1 first report to reopening and impairment exams.
West Virginia's workers' compensation forms come from the Offices of the Insurance Commissioner (OIC), while private carriers, self-insured employers and third-party administrators handle the claims. The initial treating provider completes Section II of the OIC-WC-1, the Employees' and Physicians' Report of Occupational Injury or Disease, covering diagnosis, body parts, causation and work status. The Attending Physician Benefits Form certifies the expected period of temporary total disability, the return-to-work date, MMI and readiness for a PPD rating.
Send these forms to the carrier, self-insured employer or TPA handling the claim. With the benefits form, physicians also send detailed office notes after each visit, and an incomplete form affects TTD payment. The OIC-WC-1 and the hearing loss report (OIC-WC-1HL) are Word documents. Other forms cover diagnosis updates, controlled substances, claim reopening for PPD, a low back exam and occupational pneumoconiosis (OIC-WC-3OP). All are in English.
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.
Physician's report of history, examination, X-ray and pulmonary function findings and opinion on whether the claimant has occupational pneumoconiosis.
Occupational hearing-loss claim with audiometric results and the ENT's exam, diagnosis and causation findings.
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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The initial treating health care provider, and all of Section II must be completed by that provider. It covers the diagnosis, the body parts injured, causation and work status. The employee completes Section I. The finished report is filed with the employer's private carrier, self-insured employer or third-party administrator. The OIC posts it as a Word document rather than a PDF.
The physician of record uses the Diagnosis Update form to add or update ICD-10-CM diagnoses on the claim, with the clinical findings and how each diagnosis relates to the compensable injury. Mail it to the private carrier, self-insured employer or TPA handling the claim. The OIC lists it among its Third-Party Administrator Forms.
Two clinicians share Section II. A certified or licensed audiologist completes Part A with the audiometric results, and an ENT, otologist or otolaryngologist completes Part B with the exam, diagnosis and causation findings. Only audiometry by an audiologist with CCC-A or West Virginia licensure is accepted. The employee completes Section I, and the form goes to the carrier, self-insured employer or TPA.
Through the Claim Re-Opening Application for Permanent Partial Disability. The claimant completes Section I. The treating or new treating physician completes Section II on page 2 with detailed findings on aggravation or progression, attaching a narrative report if needed. The application goes with supporting evidence to the private carrier, self-insured employer or TPA administering the claim.