Summary of 2021 Form Changes

FORM CHANGES – EFFECTIVE JULY 1, 2021

WC-P1 PANEL OF PHYSICIANS: Added “Panel of Physicians” to title.          

WC-P3 WC/MCO PANEL: Added “Managed Care Organization Procedures” to title.

WC-1 FIRST REPORT OF INJURY: Updated formatting on page 2 of the form.

WC-2 NOTICE OF PAYMENT OR SUSPENSION OF BENEFITS: Removed excess check boxes in Section B and C, added abbreviations TTD, TPD and PPD to Section A on page 2 of form, switched order of information on page 2 of form.

WC-2A NOTICE OF PAYMENT OR SUSPENSION OF DEATH BENEFITS: Updated formatting on page 2 of form.

WC-3 NOTICE TO CONTROVERT: Updated Section B, Subsections 1 and 2 for consistency, added sections A and B, updated instructions on page 2 of form to be consistent with the language in the statute.

WC-4 CASE PROGRESS REPORT: Corrected citation formatting in subtitle.

WC-10 NOTICE OF ELECTION OR REJECTION OF WORKERS’ COMPENSATION COVERAGE: Corrected citation formatting in introduction paragraph, corrected month and year in Section D, corrected citation formatting in paragraph 1 and 2 on page 2 of form.

WC-11 STANDARD COVERAGE FORM GROUP SELF-INSURANCE FUND MEMBERS: Updated formatting on page 2 of form.

WC-14 NOTICE OF CLAIM/REQUEST FOR HEARING/REQUEST FOR MEDIATION: Updated title.

WC-25 REQUEST FOR LUMP SUM OR ADVANCE PAYMENT: Changed “employee” to “claimant” throughout, updated language in Section B, box 3, Section C, and Section D, box 2.  

WC-26 CONSOLIDATED YEARLY REPORT OF MEDICAL ONLY CASES/INDEMNITY CASES: Updated language in introduction paragraph, updated formatting in Section C, updated formatting on page 2 of form.  

WC-102 REQUEST FOR DOCUMENTS TO PARTIES: Corrected citation formatting in Section B.

WC-102D MOTION/OBJECTION TO MOTION: Corrected citation formatting in introduction.

WC-108b ATTORNEY WITHDRAWAL/LIEN: Bolded paragraph in Section A, replaced “client” with “claimant”, update formatting in Section B and C.

WC-121 NOTICE OF CHANGE OF TPA/SERVICING AGENT: Updated formatting on page 2 of form.

WC-131 APPLICATION FOR PERMIT TO WRITE INSURANCE: Changed format of citation in introduction paragraph, update signature box, updated format of instructions on page 2 of form.

WC-131a ANNUAL INSURANCE UPDATE: Changed format of citation in introduction paragraph, updated format of instructions on page 2 of form.

WC-200a REQUEST/OBJECTION FOR CHANGE OF PHYSICIAN/ADDITIONAL TREATMENT: Corrected citation formatting in title.

WC-200b REQUEST/OBJECTION FOR CHANGE OF PHYSICIAN/ADDITIONAL TREATMENT: Corrected citation formatting in title.

WC-205 REQUEST FOR AUTHORIZATION OF TREATMENT OR TESTING BY AUTHORIZED MEDICAL PROVIDER: Updated Chairman’s name.

WC-206 REQUEST TO BECOME A PARTY AT INTEREST: Corrected citation formatting in title.

WC-207 AUTHORIZATION AND CONSENT TO RELEASE INFORMATION: Corrected HIPAA citation.

WC-226B PETITION FOR APOINTMENT OF TEMPORARY CONSERVATOR FOR LEGALLY INCAPACITATED ADULT: Removed address from certificate of service.

WC-240 NOTICE TO EMPLOYEE OF OFFER OF SUITABLE EMPLOYMENT: Corrected citation formatting in introduction paragraph and Section B.

WC-243 CREDIT/REDUCTION IN BENEFITS: Corrected citation formatting in introduction paragraph, removed address, format Section B.

WC-244 NOTICE OF INTENT TO BECOME A PARTY AT INTEREST: Corrected citation formatting in introduction paragraph.

WC-262 WAGE DOCUMENTATION OF TEMPORARY PARTIAL DISABILITY PAYMENTS: Formatted introduction paragraph.

WC-CATASTROPHIC REHAB RELEASE: Removed “RE” box.

WC-R1 REQUEST FOR REHABILITATION: Changed sections headers from 1,2,3… to A, B, C…, corrected spelling in Section 5.

WC-R1CATEE EMPLOYEE’S REQUEST FOR CATASTROPHIC DESIGNATION: Changed sections headers from 1,2,3… to A, B, C…, corrected spelling in Section 5.

WC-R2 REHABILITATION TRANSMITTAL FORM: Changed sections headers from 1,2,3… to A, B, C…, corrected spelling in Section 6.

WC-R3 REQUEST FOR REHABILITATION CLOSURE: Changed sections headers from 1,2,3… to A, B, C…, corrected spelling in Section 7.

WC CATASTROPHIC REHAB RELEASE: Removed “RE:” box, corrected HIPAA citation.

WC-CHANGE OF INFORMATION: Removed underlining from introduction paragraph, changed heading of Section B to “ALL OTHER PARTY CHANGE OF ADDRESS.”

WC-CHANGE OF ADDRESS:  Removed underline from introduction paragraph.

WC-PMT(b): PETITION FOR MEDICAL TREATMENT(b) FAILURE TO ATTEND MEDICAL APPOINTMENT WITH AN AUTHORIZED TREATING PHYSICIAN: Removed check box in section C, moved name of physician to middle of line.

(Revised 7/13/2021)