Medical Status Form

New - Medical Status Survey

The Department of Labor and Industry is seeking stakeholder feedback on ways to improve the Medical Status Form. Please click the link below to take a brief, 10-question survey to provide feedback on the Medical Status Form update.

Medical Status Form Survey

MCA 39-71-1036 requires that the treating physician or a designee shall complete the form following every office visit with the worker. The legislature directed the Department to create a form to be used for injuries or occupational diseases.
If you use the online version of the form, you may use the fillable PDF form.  If you prefer to use the triplicate hard copy of the form, you  may order them by emailing your request to or call (406) 444-6543.
Instructions for completing the Medical Status Form can be found on page 4.
Video Demonstration
If you have questions about the use of the Medical Status Form, you may email Celeste Ackerman at or call (406) 444-6604.
Download the Medical Status Form.
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