Sample Request for Physician’s Report of WC Injury

March 17, 2014

Below is a sample request to a medical provider for Physician’s Report of Workers’ Compensation Injury Form: 

Dear Sir or Madam:

As you may be aware, effective May 23, 2008, all doctors who are certified and who render treatment pursuant to Delaware’s Workers’ Compensation Act must complete and forward the Physician’s Report of Workers’ Compensation Injury Form to the employer, insurance carrier and to the patient within ten days of initial treatment . Specifically, 19 Del.C. § 2322E(b) states “every health care provider who evaluates or treats an employee shall complete and submit, as expeditiously as possible and not later than ten (10) days after the date of first evaluation or treatment, a report of employee condition and limitations, on a form adopted for that purpose pursuant to this Section, and shall expeditiously provide copies of the report of employee condition and limitations to the employee, the employer and the employer’s insurance carrier, if applicable.”

Enclosed is a copy of the form for your convenience.

We have not received this form from you despite the fact that 10 days have elapsed since your initial treatment.

Please note that 19 Del.C. § 2322F(g) provides for a fine of not less than $1,000 nor more than $5,000 for violations of the foregoing provision.

We look forward to receiving this form from you at your soonest convenience.

Very truly yours,