Wyoming Workers' Compensation Division forms clinicians complete, from the initial medical report and WCD-9 disability certification to surgery preauthorization.
In Wyoming, the Workers' Compensation Division of the Department of Workforce Services issues the forms and receives most provider reports. The initial treating provider, whether an MD, DC, OD or other provider, completes the Health Care Provider Initial Medical Report with history, exam findings, ICD-10 diagnosis, work-relatedness, treatment, impairment and release-to-work status. To support temporary total disability benefits, the provider certifies the worker's Application for Temporary Total Disability Benefits (WCD-9), and a separate WCD-9 covers extraordinary circumstances.
Send the initial report and the WCD-9 to the Division. On the WCD-9, the provider certifies an exam within the last 60 days. When an employer offers light duty, a licensed provider certifies on the Agreement for Light Duty/Restricted Work that the work fits the restrictions. Surgery preauthorization is voluntary in Wyoming, and surgeons send requests to the Division's preauthorization unit with the office note and recent diagnostics. Chiropractors report re-exams on their own form. All forms are in English.
Initial treating-provider report of history, examination findings, ICD-10 diagnosis, work-relatedness, treatment, impairment and release-to-work status for a Wyoming workers' compensation claim.
Injured worker's application for TTD benefits with the health care provider's certification of diagnosis, work-relatedness, restrictions, ascertainable loss and expected duration of total disability.
Written employer offer of light-duty or part-time work, with the health care provider certifying the offered work fits the employee's restrictions (W.S. 27-14-404(j)).
Voluntary request by a surgeon for Division preauthorization of a surgery or procedure (diagnosis, CPT codes, work-relatedness, recovery estimate).
Requests preauthorization of DME over $2,500, listing items with HCPCS codes, with the treating provider's order or letter of medical necessity.
TTD application with provider certification used when TTD is sought beyond the normal limit under the extraordinary-circumstances provision.
Documents chiropractic re-examination findings (complaints, range of motion, strength, PDQ scores) for a worker under active chiropractic care, or the discharge date.
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 Health Care Provider Initial Medical Report. The initial treating provider completes the whole form: history, exam findings, ICD-10 diagnosis, work-relatedness, treatment, impairment and release-to-work status. It goes to the Workers' Compensation Division in Cheyenne and satisfies the initial provider report required by W.S. 27-14-501(a)(b). The form has no printed form number, and the Division also handles claims and billing through its PIERS portal.
The certifying health care provider completes the certification on the lower part of page 1, after the worker fills in the first part. The provider confirms an exam within the last 60 days and states the diagnosis, work-relatedness, restrictions, ascertainable loss and expected duration of total disability. The certification satisfies W.S. 27-14-404 and 27-14-501(b). Return the form to the Workers' Compensation Division.
Under W.S. 27-14-404(j), an employer's written offer of light-duty or part-time work needs a health care provider to certify that the work fits the employee's restrictions. The treating physician or another licensed provider completes the Health Care Provider Certification block, and the employer and employee also sign. The employer returns it to the Division and gets account relief only if a licensed provider approved the light duty.
No, it is voluntary. A surgeon or office can send the Provider Request for Preauthorization Review with the diagnosis, CPT codes, work-relatedness and a recovery estimate. Fax or email it to the Division's preauthorization unit with the office note, recent diagnostics and any required check sheet. Higher-cost durable medical equipment has its own preauthorization request, sent with the treating provider's order or letter of medical necessity.