West Virginia workers' compensation claim administrators use this one-page form to support temporary total disability (TTD) payments. The attending physician estimates the period of disability, the transitional or full-duty return-to-work date, whether the claimant has reached maximum medical improvement and whether they are ready for a permanent partial disability rating, along with current and next appointment dates.
The attending physician completes and signs the top section. The claimant completes the bottom, certifying whether they worked or received income while certified temporarily and totally disabled.
Download the current version from the source each time; forms change without notice.
Attending Physician Benefits Form
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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 form warns that failing to complete it in full affects TTD payment, and that completing it without updated detailed medical reports, including current treatment plans, after each visit does not guarantee benefits. Check that both sections were filled out and that office notes reached the administrator.
Yes. Below the physician's section, the claimant answers whether they performed any work or received income for work while certified temporarily and totally disabled, and signs a certification that the answer is true, acknowledging penalties for fraudulent statements.