Wage and Hour/Wage Payment Act
Workers Comp Claims
Workers' Comp Claims Category
Proposed Montana Facility Fee Schedule
---
Previous EDI Notices
NOTICE(S):
Intent to Adopt Claims Release 3: On June 7, 2012, the Department of Labor and Industry announced its intention to adopt the IAIABC EDI Claims Release 3.0. The Department plans to adopt the international reporting standards on a voluntary basis in the next three to five years. This link contains the entire notice.
FROI Edit Matrix Change: Effective 11/9/2011, Montana began returning a TR (Transaction Rejected) for FROI submissions containing ‘99’ in the Part of Body Injured Code (DN0036). (Posted 11/9/2011.)
Medical Status Form - Hard Copy Request
Medical Regulations Unit Forms
The forms listed below are those commonly used in the Medical Regulation Unit functions of the workers' compensation system.
Medical Forms
Medical Status Form
Independent Medical Review Form (pdf)
Subsequent Injury Fund Forms
SIF Application (pdf)
SIF Application (word)
SIF Release Form (pdf)
SIF Release Form (word)
Medical Status Form
NOTE: After careful consideration, our office has decided to take down the revised Medical Status Form that was to be used beginning April 1. The original Medical Status Form dated 09/19/11 is available. Please continue to use the original form. We will soon repost the revised form as a “DRAFT” and will seek external input through this website. If you have registered your email on this website, you will be notified and asked if you wish to provide feedback and comments on the revised “DRAFT” form. We apologize for any confusion this may have caused. (Posted 04/11/2013)
Effective July 1, 2011, 39-71-1036, MCA, requires the treating physician or a designee to complete the form following every office visit with the injured worker. The Legislature directed the department to create the form to be used for injuries or occupational diseases occurring on or after July 1, 2011.
The form was originally finalized the first week of October 2011, and was available in a fillable PDF version, a Word version, and triplicate hard copy.
The form has been updated and is available as of April 1, 2013. The current version (dated 04/2013) of the form can be used immediately. To accommodate those who have supplies of the original form, both versions of the form are acceptable means for reporting until September 30, 2013. After September 30, 2013, only the current version of the form should be used or accepted.
Your name and e-mail are requested so we can send email notices when updates or improvements are made to the form. Once you enter this information, you will be able to download the form as a fillable PDF. The instructions are located on page 4 of the form.
Shortly, the form will be available in a Word version as well.
Use this link to request hard-copy forms.
