Independent Contractor Central Unit

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:  The DRAFT Medical Status Form is now available. As you complete page one, the information is transferred to pages two and three.  You will notice question marks in the black box on the left of each section.  Clicking the question mark will display instructions for that section.  To close the instructions and return to the form, click the X on the right.  If you prefer to view the instructions as a whole, they can be found on page four.

We would appreciate your feedback. Please provide responses and comments no later than June 28, 2013. You may email Bill Wheeler at bwheeler@mt.gov.  Download the DRAFT Medical Status Form.  (Posted 06/14/2013)

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.

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.