The treating physician completes this form and the report provides specific medical information including date of accident, diagnosis, prognosis, the disability period(s), and the extent of any permanent disability. This form must be signed by the treating physician.
In cases of amputation for hand/foot, the treating physician completes this form and may fill out the Amputation Chart.
This form may be filed electronically through the Commission’s WebFile system at http://webfile.workcomp.virginia.gov. To file electronically, the user must have a valid and active WebFile account. This form may be filed by mail or in-person at 333 E. Franklin St., Richmond, VA 23219. This form may also be filed by fax 804-823-6956.
For questions or assistance with completing this form, please contact the Virginia Workers’ Compensation Commission toll free at 1-877-664-2566 or by email at Questions@workcomp.virginia.gov.