Medical Status Form

The purpose of the Medical Status Form is to facilitate communication amongst an individual with a work-related injury or occupational disease, the employer, and the healthcare provider for stay at work and return to work planning. The form also provides functional status to the insurer.

The Medical Status Forms are available in English and Spanish.

 Medical Status Form Instructions English

English Version 1  English Version 2  English Version 3

 Medical Status Form Instructions Spanish

Spanish Version 1  Spanish Version 2  Spanish Version 3

Please see the expandable sections below for more information on the Medical Status Form.

The Department would like your feedback on how the Medical Status Form updates are working in the system. Please take a moment to answer this short, 5-question survey: How are the Medical Status Form updates working in the system?

If you have questions about the use of the Medical Status Form, you may email Celeste Ackerman at celeste.ackerman@mt.gov or call (406) 444-6604.

  • The treating physician or their designee completes the Medical Status Form after each visit to communicate information about the injured worker’s work status, as below.

    • Current work capacity;
    • Modified work abilities, if applicable;
    • Maximum medical improvement (MMI) status; and
    • Follow up visit.

    Completion of the Medical Status Form is statutorily required, as per 39-71-1036, MCA, which states, "the department shall create a medical status form to be provided to a health care provider providing treatment for a compensable injury or occupational disease." An insurer may request additional information from the healthcare provider not contained in the form. The treating physician or a designee is required to complete the form following every office visit with the worker. Only one version of the form should be completed after each visit. The selection of the form version is at the treating physician’s discretion.

  • Information provided on the Medical Status Form is useful for all workers’ compensation stakeholders.

    • Injured workers understand activities they can do in the work and home setting.
    • Providers can communicate key information about medically safe activities in a timely, effective, and appropriate manner.
    • Employers can develop timely and safe modified work plans to accommodate the injured worker while they are recovering.
    • Claim examiners understand the injured worker’s functional progress, timing of the next medical evaluation, and medically safe activities for the injured worker.

  • Completion of the Medical Status Form is statutorily required following each visit, as per 39-71-1036, MCA, which states, “The treating physician or a designee shall complete the form following every office visit with the worker.” Only one version of the form should be completed after each visit. The selection of the form version is at the treating physician’s discretion.

  • Treating physicians in the Montana workers’ compensation system are primarily responsible for the delivery and coordination of the worker’s medical services for the treatment of a compensable injury or occupational disease. Eligible licensed providers are statutorily defined in 39-71-116, MCA, to include physicians, chiropractors, physician assistants, dentists, advanced practice registered nurses, and physical therapists.

  • DLI offers instructions and three versions of the Medical Status Form. Only one version of the form should be completed after each visit. The selection of the form version is at the treating physician’s discretion. These forms are available in English and Spanish.

    Section 1: Employee/Provider Information

    Complete all fields.

    Section 2: Work Capacity

    At least one selection is required. When “Released to Modified Duty” is selected, the provider or their designee must complete Section 3, “Modified Work Abilities” and Section 4, “Status Updates.” When “Employee May Work Limited Hours” is selected, add the number of hours per day and complete Section 3, if applicable, and Section 4.

    Section 3: Modified Work Abilities

    In this section, the provider or their designee indicates the injured worker’s work abilities to help the employer identify appropriate modified duties in the workplace.

    The provider or their designee may indicate whether they would like a copy of the individual’s job description; the body part to which the restrictions apply; and whether there are daily work hour restrictions.

    Section 4: Status Updates

    Work status:

    This field allows the provider to estimate when the individual will be ready to trial full duty work.

    Maximum medical improvement (MMI) and impairment rating status:

    This field allows the provider to indicate whether the individual has reached MMI with an applicable date or when they anticipate the individual will reach MMI. There is also a check box to indicate a request for an independent medical evaluation or an impairment rating.

    Follow up:

    The provider can indicate the desired date or duration before follow up evaluation.

    Signature, print, and date fields:

    As per 39-71-1036, MCA, the treating physician or their designee can complete and sign this form.

    Medical providers can program the form to work within their electronic medical record if the name of the form remains the same and all the data fields are included.

  • Medical restrictions may prevent an employee from returning to their regular job after a workplace injury. However, it may be possible to return to work in a modified capacity during recovery. Research shows the sooner an individual returns to work, the more likely they will preserve future income and health. A provider’s detailed description of medically safe work restrictions is most helpful for employers as they attempt to find modified work. Avoid vague or nonspecific phrases that do not aid in return-to-work efforts.

  • Modified duty work is work the employer offers within the provider’s medical restrictions that allows the injured worker to safely perform work while they recover. Modified duty doesn’t have to be directly related to the work an employee performed prior to injury.

    Modified work might involve any of the following:

    • Working shorter hours.
    • Doing some of the original duties part time and then gradually increasing to full time work.
    • Performing different duties with lighter physical demands and progressing to the original duties.
    • Adjusting the job or worksite to meet the physical limitations by providing tools, equipment, or appliances.
    • Creating a new job within the medical restrictions while the injured worker recovers.

    Some injuries are so severe the injured worker cannot return to work right away. However, with most injuries, an early and medically approved return to work makes sense. Employers may talk with their employee about work they may be able to perform while they heal.

  • The injured worker, the employer, and the claim examiner receive a copy of the Medical Status Form. The provider’s office is responsible for ensuring all three parties receive a copy of the form.

  • Figueredo, J.-M., Garcia-Ael, C., Gragnano, A., & Topa, G. (2020). Well-Being at Work after Return to Work (RTW): A Systematic Review. International Journal of Research in Public Health.

    International Association of Industrial Accident Boards and Commissions. (2021, January 22). A How-To Guide for Work and Disability Prevention. Retrieved from https://lni.wa.gov/patient-care/_docs/How-to-Guide-Injury-Disability-Prevention_January-2021_Executive-Summary.pdf

    United States Department of Labor Office of Disability Employment Policy. (2026, March 4). Stay at Work/Return to Work. Retrieved from https://www.dol.gov/agencies/odep/initiatives/saw-rtw#:~:text=Early%20stay%2Dat%2Dwork/return%2Dto%2Dwork%20(SAW/RTW)%20strategies%20and%20programs%20aim,them%20at%20risk%20of%20leaving%20the%20workforce

    WorkSafe BC. (2026, March 4). Return to Work. Retrieved from WorkSafe BC: https://www.worksafebc.com/en/claims/return-to-work