South Carolina workers' compensation settlements and hearings often rely on this one-page statement from the treating or evaluating physician. It gives the diagnosis, the date of maximum medical improvement, permanent impairment ratings by body part and their basis, permanent limitations, retained hardware, and the future medical care the claimant needs. All opinions are stated to a reasonable degree of medical certainty.
The treating or evaluating physician, or another licensed health care provider authorized to treat or evaluate the claimant, completes and signs it. The form also has a separate field for the preparer's name.
Download the current version from the source each time; forms change without notice.
Physician's Statement
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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The treating or evaluating physician signs it. The certification also allows another licensed health care provider who was authorized to evaluate or treat the claimant. The signer certifies having personally read and prepared the document and that the opinions reflected on it are their own.
Say whether the claimant needs medical, surgical, hospital or other treatment that will tend to lessen the period of disability or maintain the current level of function, and describe it. The form warns that saying care 'may be necessary' or 'might be necessary' is not sufficient and will prompt a request for clarification.