Information for Medical Providers
New and/or Revised Forms and Procedures and New Medical Motion Procedures
On April 1, 2008, all Employer/Carrier/Administrators received the following notice in the Form 18 Acknowledgment letter: “ATTENTION EMPLOYER/CARRIER/ADMINISTRATOR: Within 30 days after receipt of the Form 18, you must file a Form 21, 60, 61, or 63 to admit, deny or pay without prejudice. The failure to comply with this requirement will subject you to sanctions.”
During the implementation period of April 1, 2008 through July 31, 2008, no sanctions were imposed.
New or Revised Forms:
In compliance with N.C. Gen. Stat. §97-78, effective August 1, 2008, the Industrial Commission adopted new and/or revised Forms 18, 19, 25R, 26, 26A, 60, and 63 (all revised 8/6/08) through Minutes. Please click here for a summary of instructions regarding related policies and procedures and here for complete instructions.
Rating Guide
This section is made available to the physicians of the State of North Carolina as a guide in rating industrial accidents. It has been felt that a reference point was needed by physicians in making impairment evaluations. This section is intended to be used only as a guide and basic outline for physicians making rating examinations of individuals who have had industrial injuries to their spine or extremities. Please Click Here to see the Rating Guide.
Medical Status Questionnaire
This questionnaire, which has been approved by the North Carolina Industrial Commission, may be submitted by an employer/insurer paying compensation for an admitted workers’ compensation claim to medical providers who have treated an employee for a work-related injury or condition.Please Click Here for the Questionnaire.
Medical & Rehabiltiation Forms
Form 25C
Authorization for Rehabilitation Professional to Obtain Medical Records of Current Treatment. Please fill out this form completely, sign it and mail it to the rehabilitation professional named on the form.
Form 25C - MS Word
This is the Form 25C in Microsoft Word Format. Right-Click on the link to download the form.
Referral Form
Medical Rehabilitation Nurses Section Referral Form.
Please fill out this form completely, making sure to include the I.C. Number for the claim. Please fax the
completed and signed Form 25N to
(919) 807-2616, ATTN: Judy Fisher.
The completed form can be mailed to us at:
- NC Industrial Commission
4341 Mail Service Center
Raleigh, NC 27699-4341
ATTN: Judy Fisher
You can also EMail your Form 25N in MS Word or PDF format to 25n@ic.nc.gov.
Referral Form - MS Word
Medical Rehabilitation Nurses Section Referral Form in Microsoft
Word Format.
Right-Click on the link to download the form.
Form 25N
Notice to the Commission of Assignment of Rehabilitation
Professional.
Please fill out this form completely, making sure to include the I.C. Number for the claim. Please fax the
completed and signed Form 25N to
(919) 807-2616, ATTN: Judy Fisher.
The completed form can be mailed to us at:
NC Industrial Commission
4341 Mail Service Center
Raleigh, NC 27699-4341
ATTN: Judy Fisher
You can also EMail your Form 25N in MS Word or PDF format to 25n@ic.nc.gov.
Form 25N - MS Word
This is the Form 25N in MS Word Format.
Right-Click on the link to download the form.
Form 25R
Evaluation of Permanent Impairment.
A copy of this form must be provided to the employee or the employee's attorney of record, if any. The original should be mailed to us at the Industrial Commission.
Workers Comp. Medical Status Questionnaire
The Workers Comp. Medical Status Questionnaire may be submitted by an employer/insurer paying compensation for an admitted workers' compensation claim to medical providers who have treated an employee for a work-related injury or condition.