Forms
Our members have contributed a variety of useful resource materials for attorneys and others who are involved in investigating, managing, and litigating Wisconsin worker’s compensation claims. This resource page includes various forms in MS Word and MS Excel formats.
Department Official Forms
Hearing Forms
- Hearing Summary Form
- Contributed by Phil Lehner.
- Exhibit List – Applicants’
- Contributed by Phil Lehner.
- Exhibit List – Respondents’
- Contributed by Phil Lehner.
Medical Forms
- Medical Treatment Statement, WKC-3 (R. 02/2010)
- Voluntary and Informed Consent for Disclosure of Health Care Information, WKC-9488 (R. 03/2009)
- This is the MS Word version of the Department’s revised medical authorization form.
- The form has been extensively revised to comply with the HIPAA Privacy Rule. It is now two pages and the employee must sign the form on the bottom of both pages. If Option B is checked on the form, then the employee must also sign in the box next to that option. Keep in mind that you are not supposed to modify the standard state form.
- Practitioner’s Report on Accident or Industrial Disease In Lieu of Testimony, WKC-16-B (R. 10/2010)
Miscellaneous
- Advancement or Lump Sum Request Form, WKC-136 (R. 07/2001)
- Work Search Record
- Recommended for use on LOEC claims, to document work search by applicant. Contributed by Tom McSweeney.
Social Security Reverse Offset [ยง102.44(5) Stats]
- WKC-6156 Social Security Information Request – Instr and Form
- WKC-6119 Social Security Reverse Offset – Instr and Form
- SSA Triennial Redeterminations
- Department’s 1987 Memo on SSDI Offsets
- In computing SSDI offsets, the Department’s memo of 1987 is still relevant.
- Sample computations for 1987 Memo