Summary of 2024 Form Changes

FORM CHANGES – EFFECTIVE JULY 1, 2024

WC-PMT(b):  Amend form WC-PMT(b) “Petition for the Medical Treatment; Failure to Attend Medical Appointment with an Authorized Treating Physician” to include additional language in bold. Section D of this form will be amended to state “The employee has failed to attend a medical appointment as agreed or as directed by a previous order of the Board. Supporting documentation is attached. Petitioner requests the Board to issue a notice of telephone conference during which the employee and/or the employee’s attorney shall be directed to show cause why the employee’s disability benefits should not be suspended.

WC-121: Amend form WC-121 “Notice of Change of TPA / Servicing Agent” to include additional language in section headings B and C. The heading in section B will be amended to “Name of Claims Office Being Terminated for all OF ITS Claims”, and the heading in section C will be changed to “Notice of Replacement Claims Office for all Claims in Section B.” The form instructions will also be amended to reflect the form applies to all claims both new and legacy. This change provides further reporting clarification to Insurers, Self-Insurers, and Group Fund.

WC-207: Change form WC-207 “Authorization and Consent to Release Medical Information” to remove the employee/patient’s social security number. Social security numbers were removed from all other Board forms effective December 1, 2018. The WC-207 form shall not be filed with the Board, unless otherwise requested.

WC-226(a): Amend form WC-226(a) “Petition for Appointment of Temporary Conservator of Minor(s)” to include a signature line for the Petitioner in the verification section of this form. The verification section must be notarized by a Notary Public.

WC-226(b): Amend form WC-226(b) “Petition for Appointment of Temporary Conservator for Legally Incapacitated Adult” to include a signature line for the Petitioner in the verification section of this form. The verification section must be notarized by a Notary Public.