Medical Status Form

The REVISED Medical Status Form is now available. Based on feedback from medical providers, the Department determined there was a need to revise the form. The revised form reflects this input from medical providers as well as feedback received from other stakeholders in the system.

If you use the online version of the form you may immediately begin using the revised fillable PDF form. If you use the triplicate hard copy of the form, please continue to use the forms you have on hand until your supplies are depleted. When you order new triplicate hard copy forms from the Department, they will be the revised Medical Status Form.

The revised form offers on-demand instructions. You will notice question marks in the black box on the left of each section. Clicking on the question mark will display specific instructions for that section. To close the instructions and return to the form, click the “X” on the right upper corner of the instruction window. The complete instructions may be found on page four.

If you have any questions about the use of the Medical Status Form and/or would like to schedule training, you may email Celeste Ackerman at or call at (406) 444-6604.  If you desire to order the triplicate hard copy of the form, please email your request to or call (406) 444-6543.

Note: Effective July 1, 2011, 39-71-1036, MCA, requires the treating physician or a designee to complete the form following every office visit with the injured worker. The Legislature directed the Department to create the form to be used for injuries or occupational diseases. The form was originally finalized the first week of October 2011.

Download the Medical Status Form.

Training Webinar

Learn how to use effectively use the Medical Status Form in this webinar by Dr. Carla Huitt.

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