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 with the Commission in the following ways:
- ONLINE: WebFile users may upload this form through their account. Click here to learn more about WebFile.
- FAX: Fax the complete form to 804-823-6956.
- MAIL: Mail the completed form to 333 E. Franklin St., Richmond, VA 23219.
- IN PERSON: Bring the completed form to any of our VWC Office Locations.
For questions, please contact the Commission toll-free at 1-877-664-2566 or by email at Questions@workcomp.virginia.gov.