Florida's Division of Workers' Compensation requires physicians to use this two-page form, adopted in Rule 69L-7.730, F.A.C., to report an injured employee's medical status to the insurer. It records work-relatedness, objective findings, major contributing cause, patient classification, the treatment plan, functional limitations and, when reached, maximum medical improvement and the impairment rating. Completing Section III also serves as the provider's written request for insurer authorization.
Physicians who provide direct billable services complete it, including physician assistants and ARNPs under physician supervision, limiting answers to their area of expertise; emergency room physicians complete items 1 to 8, 10 to 12, Section IV and the attestation. A non-physician provider who rendered billable services at the visit signs the second attestation in Section VII.
On the first form, complete the insurer name, visit or review date, patient name, date of birth, date of accident, employer and whether this is the initial visit with you; items 2, 3, 4 and 6 are required on every later form. Item 2 is the date of service, the 30-day review date, or the date of a change in clinical status or treatment, including a prescription change.
Check item 9 if items 10 to 13d are unchanged since the last report. Otherwise mark work-relatedness (item 10; if not work related, sign the attestation and submit), whether objective relevant medical findings exist (item 11, with an explanation), descriptive diagnoses (item 12, not ICD codes alone) and every major contributing cause question in item 13. The work injury must contribute more than 50 percent, and pain without objective relevant findings is not compensable.
Check at least one of items 14 to 17. Level I is a specific, well-defined condition whose objective findings match the complaints. Level II is regional or generalized deconditioning that calls for physical reconditioning. Level III is poor correlation between complaints and objective findings, with non-somatic factors, calling for interdisciplinary rehabilitation. The level should match the physical medicine option requested in item 20c.
Check item 18 only when no further care, including medication management, is needed; MMI must then be established and an impairment rating assigned. Check item 19 if items 20a to 20g are unchanged. Otherwise check each service requested in item 20: consult, referral or transfer of care with the specialty, diagnostic tests, physical medicine with specific instructions, named drugs, DME with quantity, surgery (CPT codes allowed) and attendant care level, frequency and duration.
Check one item. Item 21 means no limitations, with the date of release to full activity. Item 22 means the patient cannot work even at a sedentary level, with details and an effective date. Item 23 allows return to activity with restrictions: name the joint or body part and, for each limited activity, give load, frequency and duration, and range of motion or position. Restrictions apply on and off the job until the next appointment.
Item 24 records whether MMI has been reached and its date, not reached, an anticipated MMI date, or not yet determinable; once MMI is set, check whether future medical care is anticipated. Items 25 and 26 give the whole-body impairment percentage, the body part or system and the rating guide used. Item 27 records whether residual dysfunction or functional loss is expected. Mark which item 23 restrictions are permanent.
Enter the next scheduled appointment date and time in item 28. If no appointment is set, give a brief explanation such as as needed, discharged from care or transfer. The limitations and restrictions in Section IV stay in effect until this appointment unless they are noted otherwise or modified before that date.
The physician completes the physician group, date, signature, DOH license number, printed name and specialty, attesting that the answers are made to a reasonable degree of medical certainty based on objective relevant medical findings, match the medical record and have been shared with the patient, and certifying any MMI or impairment information. A non-physician provider who rendered billable services that visit signs the second attestation; otherwise enter N/A.
Download the current version from the source each time; forms change without notice.
Florida Workers' Compensation Uniform Medical Treatment/Status Reporting 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.
Sources for this guide
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The physician who first treats the injury submits within 3 business days of the date of service, a condition for the medical claim to be valid under section 440.13(4)(a), F.S. Subsequent treating, consulting and referral physicians submit by close of business the next business day after each visit, or within 30 days of the prior form even without new information.
Yes. Physician assistants and advanced registered nurse practitioners under a physician's supervision who provide direct billable services must complete it. Only a physician may establish the date of maximum medical improvement and assign a permanent impairment rating under section 440.15(3)(d)1, F.S., and the physician completes the main attestation in Section VII.
Yes. The instructions allow an electronic signature in place of an original physician signature, and electronic or fax submission when the insurer agrees. An ink-stamped signature is not an acceptable substitute. The physician remains responsible for the accuracy and completeness of everything submitted and for the attestation statement.
It depends on the date of accident: the AMA Guide through 6/30/90, the Minnesota Disability Schedules from 7/1/90 to 10/31/92, the 1993 Florida Impairment Guide from 11/1/92 to 1/6/97, and the 1996 Florida Uniform Permanent Impairment Rating Schedule from 1/7/97 on. Check item 26a for the 1996 schedule, or 26b and name the other guide.