New Hampshire requires this one-page medical form at every workers' compensation visit with an MD, DO, DC or DDS, filed with the insurance carrier within 10 days of treatment, first aid excluded. It records the worker's account and complaints, diagnosis and prognosis, treatment plan, a causation opinion, work capability with detailed restrictions, maximum medical improvement and permanent impairment, which helps the employer offer temporary alternative work.
The treating health professional completes the 'Health Professional to Complete' section and signs the certification with printed name, telephone and federal ID number. The employee, employer and insurer details at the top identify the claim.
Download the current version from the source each time; forms change without notice.
New Hampshire Workers' Compensation Medical Form
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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At each health professional visit with an MD, DO, DC or DDS on the claim, not just the first one. Each form must be filed with the workers' compensation insurance carrier within 10 days of the treatment. First aid treatment is excluded from the requirement.
The form states that failing to complete and file it results in the provider not being reimbursed for services rendered and may result in a civil penalty. All medical notes must also be attached to the bill, so the form, notes and bill go to the carrier together.
The form's medical authorization note, citing RSA 281-A:23 V(a), says the worker's act of applying for benefits authorizes physicians, hospitals, chiropractors and other medical vendors to supply relevant medical information, including past history of similar complaints, to the insurer, employer, the worker's representative and the department.