Forms Library

• Workers’ Compensation Pharmacy Card

  Use this link to complete a card that the injured employee can use to avoid paying out of pocket for medications related to the injury. Learn more about Pharmacies Finding a Pharmacy

• Panel Physician Form (PDF)

  Use this form to offer a panel of physicians to the injured worker. Learn more about Physician Panels

• Physical Capabilities Evaluation Form (PDF)

  Use this form to evaluate the Injured Worker’s job and the physical demands needed to complete it. Learn more about Physical Capabilities Evaluation

• Supplementary Report (PDF)

  Use this optional form any time there is a change in the injured worker’s work status which results in lost time or return-to-work and will affect the amount of indemnity benefits the injured worker is owed. Learn more about Reporting an Injury

• Agency Contact Form (PDF)

  Use this form to add or make changes to agency contacts and system access information.

• Mileage Reimbursement Form (Word Doc)

  This form is used exclusively for mileage reimbursement.

• Medical / Pharmacy Reimbursement Form (XLS)

  Complete this form when the injured worker has out of pocket expense for medical care or approved pharmacy prescriptions.

• Injury Type Checklists (PDF)

  Use these checklists to arm yourself with the most common types of information the benefit coordinator will need in order to complete their investigation.

• Virginia Workers’ Compensation Commission Forms

  This link will direct you to the Virginia Workers Compensation Commission website for a complete list of state forms.

• Wage Chart (PDF)

  Use this Virginia Workers’ Compensation Commission form to report an injured worker’s gross earnings for the 52 weeks immediately preceding the date of injury.

Adobe Acrobat Reader is required to view PDFs. It can be downloaded for free from Adobe’s website.

For questions on any of the forms, call MCI at (804) 344-0009 ext. 302 or email at [email protected].