This form may be used by legal counsel to request Full and Final Mediation by a Commission mediator as a means of reaching a compromise settlement. Filing instructions are included on the form. Once the form is received, ADR Department staff will contact all other parties to confirm whether they are also interested in mediating the dispute.
This form may be used by injured workers, deceased worker claimants, medical provider claimants, employers, insurers, claim administrators, and legal counsel to request Issue Mediation by a Commission mediator as a means of resolving a claims dispute. Filing instructions are included on the form. Once the form is received, ADR Department staff will contact all other parties to confirm whether they are also interested in mediating the dispute.
The treating physician completes this form to provide information to support an injured worker’s claim which resulted in amputation to the foot, toes or metatarsal bones and/or hand, fingers or metacarpal bones.
The physician should complete this form with a straight line drawn at the exact point of amputation. Circles are not acceptable. This will allow the Commission to determine an accurate entitlement of permanent partial disability benefits.
Payment for services that the employer does not contest, deny, or consider incomplete shall be made to the health care provider within 60 days after receipt of each separate itemization of the health care services provided. Whenever there is a disagreement on the application or interpretation of the MFS Rules between a provider and a payer, either party may submit a MFS Dispute Request Form along with supporting documentation to the Medical Fee Services Department for administrative review and determination.
Payment for services that the employer does not contest, deny, or consider incomplete shall be made to the health care provider within 60 days after receipt of each separate itemization of the health care services provided. Whenever there is a disagreement on the application or interpretation of the MFS Rules between a provider and a payer, either party may submit a MFS Dispute Request Form along with supporting documentation to the Medical Fee Services Department for administrative review and determination.
This form describes the mediation process and related Code of Virginia provisions. When one or more parties to a mediation does not have legal counsel to represent them at the mediation, Mediation Consent Form B is used, which requires a neutral facilitation style by the mediator (see paragraph 7).
This form describes the mediation process and related Code of Virginia provisions. When all parties to a mediation have legal counsel to represent them at the mediation, Mediation Consent Form A is used, which allows the parties to choose a neutral evaluation style and/or a neutral facilitation style by the mediator (see paragraph 7).
The Revocation of Prior Rejection of Coverage Form (Form 17A) may be filed by an executive officer or their agent in the event the officer wishes to revoke the officer’s prior rejection of coverage under the Act filed with the Commission. The Form 17A must be completed fully, provided to the employer and filed with the Commission.
Click here to file the Notice Terminating Prior Rejection of Coverage (Form 17A) online.
This form may be used by employers, insurers, or claims administrators to notify the ADR Department whether a Medical Provider Application
The Referral for Lack of Coverage Form is offered by the Commission for the public to report an employer suspected of operating in Virginia without workers’ compensation insurance when it is believed the employer is required to carry coverage under the Act.
An employer is required to carry coverage in Virginia when they have more than two part-time or full-time employees. For a contractor that hires subcontractors to assist them in their work, the contractor must count subcontractors’ employees as well as their own.
