Missouri treating physicians use this one-page form to report what treatment they gave an injured worker and the results. It covers the injury as described, first treatment date, treatment, surgery, hospitalization, physical rehabilitation, referrals, lost time, return-to-work status with temporary or permanent restrictions, next appointment, any disability rating, and total medical cost. A brief narrative accompanies the final report when appropriate.
The treating physician completes the whole form and signs it, adding license number and contact details.
Download the current version from the source each time; forms change without notice.
Medical Treatment 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 the initial treatment, at completion of treatment, and any time the Division of Workers' Compensation requests a report. The form goes to the employer or its insurer, with a brief narrative attached to the final report when appropriate.
The Division defines it as no more than five pages describing the course of treatment, the diagnosis, the evaluation for permanent injury, and the need for future medical treatment, if any. It is attached to the final report when appropriate.