Try for free

West Virginia Workers' Comp Low Back Examination Form

West Virginia workers' compensation administrators use this six-page form to standardize lumbar spine exams for claim reopening, impairment rating, 120-day, consultation, independent or comprehensive examinations. The physician records inspection, palpation, gait, squat, inclinometer range of motion with validity certification, strength, sensation, reflexes, straight leg raising, a somatic amplification score, imaging, diagnoses and recommendations.

Who completes it

The examining physician completes pages 1-4 in black ink and signs. Pages 5-6, the back pain history, are completed by the patient with assistance permitted, and the physician submits them with the exam.

Submitting and payment

How to submit it
Return the full form to the private carrier, self-insured employer or third-party administrator administering the claim.
Who pays
The OIC form does not set a fee for the examination or say who pays the physician.

Good to know

  • An inclinometer is required for impairment examinations, and thoracolumbar motion is valid only if the four AMA Guides criteria certified on page one are met.
  • Sacral motion is subtracted from T12 motion, with the form citing the AMA Guides, 4th edition.
  • The printed diagnosis list shows old numeric codes such as 847.2 even though the item asks for ICD-10 codes, so enter current ICD-10 codes yourself.
  • Differential straight leg raising compares seated and supine results as one part of the somatic amplification score.

Get the official form

Download the current version from the source each time; forms change without notice.

Low Back Examination

Official pagePDF

Fill it with Vero

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.

See how Vero Documents works

How this list is checked

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.

Frequently asked questions

When is West Virginia's Low Back Examination form used?

For lumbar exams on workers' compensation claims: claim reopening, impairment ratings, 120-day examinations, consultations, independent examinations and comprehensive examinations. The physician checks one or more exam types at the top of page 1, and the completed form goes to the claim administrator.

Does the patient fill out part of the low back exam?

Yes. Pages 5-6, the patient history for back pain, are completed by the patient with assistance permitted and cover present and past history, work details, medications and a pain drawing. The form states the physician must submit it with the low back exam.