Medical Status Form

Following the DLI Medical Status Form Stakeholder meeting on 06/18/25, DLI continues to actively seek stakeholder feedback on the Medical Status Form updates under consideration.
 
Proposed Medical Status Form Drafts 
 
Here is a link to the recording of the 06/18/25 Stakeholder meeting:
Recap: Medical Status Form Stakeholder Meeting Wednesday, June 18
 

Please review the proposed Medical Status Form drafts and provide your input via the link below:

Submit Medical Status Form Input Here 

 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 dlierdmedicalstatusform@mt.gov 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 celeste.ackerman@mt.gov or call (406) 444-6604.
 
Download the Medical Status Form.