Forms Library

Click to Download	Description

Panel Physician Form (PDF)	Use this form to offer a panel of physicians to the injured worker. Learn more about Physician Panels >

Referral Form for Field Medical or Vocational Services (PDF)	Use this form to request Return to Work services. Learn more about the Return to Work program >

Physical Capabilities Evaluation Form (PDF)	Use this form to evaluate the Injured Worker's job and the physical demands needed to complete it. Learn more about Physical Capabilities Evaluation >

Mileage Reimbursement Form (XLS)	This form is used exclusively for mileage reimbursement.

Medical / Pharmacy Reimbursement Form (XLS)	Complete this form when the injured worker has out of pocket expense for medical care or approved pharmacy prescriptions.

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For questions on any of the forms, call MCI at (804)344-0009.