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NM WCA Form Letter to Health Care Provider

In New Mexico workers' compensation cases, a party who needs the treating provider's opinions can send this Workers' Compensation Administration form letter. Its 15 questions cover treatment dates, diagnosis, causation, ability to work, time off work, MMI, impairment rating with the AMA Guides edition and pages, any functional capacity evaluation, work and activity restrictions, and referrals, all answered to a reasonable medical probability.

Who completes it

The treating physician or health care provider answers the questions pertinent to the worker's claim and signs the affirmation with printed name and address. The requesting party fills in the return address, provider and worker details before sending it.

Submitting and payment

How to submit it
Return the completed letter to the requesting party named at the top, give one copy to the worker, and send the bill for completing it to the claims administrator.
Who pays
The maximum allowable fee for completing the form is set in the WCA health care provider fee schedule and is billed to the claims administrator.

Good to know

  • Answer the questions you believe are pertinent to the claim, basing each answer on a reasonable medical probability, which is the standard the signature affirms.
  • The restrictions chart rates lifting from 5 lbs to over 50 lbs, walking, standing, sitting, and pushing or pulling arm and leg controls as never, occasionally or frequently.
  • If an impairment rating has already been assessed, give the percentage, whole body or body part, the AMA Guides edition and the page numbers used.
  • The WCA lists this letter among its optional legal forms and posts it in both PDF and Word formats.

Get the official form

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

Form Letter to Health Care Provider

Official pagePDFWord file

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Do I have to answer every question on the NM WCA form letter?

No. The instructions ask the provider to answer all questions believed to be pertinent to the worker's claim and to base answers on a reasonable medical probability. The provider then affirms that the responses are true and correct to a reasonable medical probability and signs.

Who pays for completing the New Mexico form letter?

The claims administrator. The instructions say the maximum allowable fee for completing the form is set in the WCA health care provider fee schedule and that the bill for completing it should be sent to the claims administrator.

Does the worker get a copy of the form letter?

Yes. The instructions ask the provider to give one copy of the completed form to the worker. The original goes back to the requesting party whose name and address are filled in at the top of the letter.