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DC Form 12 Medical Report (Workers' Compensation)

For private-sector workers' compensation claims in the District of Columbia, the attending physician files this one-page Medical Report with the Office of Workers' Compensation. It covers how the accident happened, diagnosis, any permanent defect, prior impairment, causation, treatment, X-rays, hospitalization, expected length of disability and the date the worker can resume regular work.

Who completes it

The attending physician completes the sections marked 'For use of physician' and signs with their IRS number. The header also asks for employee, employer, carrier and policy details.

Submitting and payment

How to submit it
File it immediately with the DOES Office of Workers' Compensation and the employer or carrier; the form warns that failing to file within 20 days under section 8(d) can delay payment.
Who pays
As the form warns, filing beyond 20 days can delay both the worker's benefits and payment for the physician's services.

Good to know

  • Expected disability is chosen from 2 weeks, 1 month, 3 months, 6 months or longer, or unknown; item 26 asks whether the patient will ever resume the regular occupation.
  • Item 13 asks who engaged the physician's services, and items 18 to 20 ask whether anyone else treated the patient and when.
  • DC government employees are not covered by this form; their claims go through the Office of Risk Management's public-sector program.
  • DOES also lists the form as OWC-12. The posted PDF has no printed revision date.

Get the official form

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

Medical Report

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

When must the DC Medical Report be filed?

The form says it shall be filed immediately, and that failing to comply within twenty days, under section 8(d), can cause unnecessary delay in paying the injured worker's benefits and paying for the services rendered. It goes to the DOES Office of Workers' Compensation and the employer or carrier.

Who uses DC Form 12?

The attending physician treating a private-sector employee injured at work in the District of Columbia. Employees of the DC government are handled through the Office of Risk Management's public-sector workers' compensation program instead.

What causation question does DC Form 12 ask?

Item 10 asks whether, in the physician's opinion, the injury and disability result from the accident as the patient described it in item 4. Items 6 to 8 ask about permanent defects and any physical impairment from a previous injury or disease.