West Virginia workers' compensation administrators accept this one-page form from the physician of record to update the diagnoses on a claim. The physician lists up to four ICD-10-CM codes in order of severity with descriptions, then gives the clinical findings behind the current diagnosis and explains how the present condition relates to the compensable injury.
The physician of record completes the claimant and physician information, including the physician's FEIN, and signs and dates it.
Download the current version from the source each time; forms change without notice.
Diagnosis Update
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 physician of record on the claim. The form's instructions say it is intended for the physician of record to update diagnostic information. That physician lists the codes and findings, signs and dates the form, and mails it to the carrier, self-insured employer or TPA.
ICD-10-CM. The form has numeric code fields for one primary and three secondary diagnoses, listed in order of severity, with matching descriptions below. It also asks for the clinical findings supporting the diagnosis and how the condition relates to the compensable injury.