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Kentucky Form 107: Injury, Hearing Loss, Psych Report

Administrative law judges in Kentucky workers' compensation litigation rely on this report for the medical side of an injury, hearing loss or psychological claim. The physician records history, treatment, examination findings, testing, surgery, diagnosis, causation, whole person impairment under the AMA Guides with chapter and table citations, maximum medical improvement, and restrictions. One combined form replaced the older 107-I, 107-HL and 107-P versions.

Who completes it

A treating or evaluating physician, including university evaluators, completes sections A through M and signs the M certification. The physician attaches a CV unless they have a Department of Workers' Claims Physician Index Number.

Submitting and payment

How to submit it
The party offering the report files it in the claim through the Department's litigation system; attorneys can also generate it from the Litigation Management System web form.
Who pays
The form sets no fee and does not say who pays for the report.

Good to know

  • Section K requires the AMA Guides edition directed by statute, citing chapter, table and page for each body part; psychiatric conditions use the class of impairment.
  • Opinions must rest on reasonable medical probability, not possibility, and objective findings mean direct observation and standardized testing (KRS 342.0011(33)).
  • Section J asks whether the work event caused the impairment, any other cause, and where relevant whether hearing loss fits hazardous noise or a psychological condition follows a physical injury.
  • October 2016 Edition, incorporated in 803 KAR 25:010, now recodified as 120 KAR 1:010. The PDF is not fillable.

Get the official form

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

Medical Report - Injury/Hearing Loss/Psychological Condition

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.

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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.

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Frequently asked questions

Do I need to attach a CV to Kentucky Form 107?

Yes, unless you have a Department of Workers' Claims Physician Index Number. Physicians join the index by sending a current curriculum vitae with a request for inclusion to the Department's Physicians Index Clerk, and the index number then stands in for the CV attachment.

Which AMA Guides edition does Kentucky Form 107 use?

The edition currently directed by Kentucky statute and regulation. The instructions say the AMA Guides are mandated by statute and ask physicians to become familiar with that edition before completing the form, citing chapters, tables and pages for all physical injuries.

Is Form 107 used for occupational disease claims?

No. Occupational diseases, including pneumoconiosis and other lung or heart conditions, use Form 108-OD, which adds employment and exposure history and ILO x-ray classification. Form 107 covers injuries, hearing loss and psychological conditions.