The Short Answer
The Workers' Compensation Medical Status Questionnaire is a standardized form used in North Carolina — available on the NC Industrial Commission's website — that allows an employer or their insurance provider to ask your treating physician specific questions about your diagnosis, prognosis, and ability to return to work. The form covers things like work restrictions, treatment plans, medications that may affect job performance, and whether your job duties caused or aggravated your injury. Importantly, your employer does not need your permission to send this form to your doctor, as authorized under NC General Statute Section 97-25.6(c)(2). Once completed, the physician must provide the responses to both the employer or insurer and to you and your representative.
What if you are injured at work and your employer or their insurance provider want to know from the doctor the status of your injury? One of the ways they can do this is by simply requesting the treating physician to fill out a Medical Status Questionnaire to the physician. This is a form that allows them to ask specific questions regarding your diagnosis and/or prognosis. The employer/insurance provider will also need to attach a description of your position with them, as that may be necessary for the physician to consult for the answers to some of the items. They can also request from the physician that they include the answers on the form itself, in medical notes or in a letter to the employer or their insurance provider. Of course, if the physician does not have enough information to have an opinion on any of the items, they are not required to answer them. The medical status questionnaire can be found on the North Carolina Industrial Commission’s website.
Most of the items that are included in the questionnaire pertain to when the employee will be able to return to work and what, if any, limitations the employee will need when they return as a result of the injury. The diagnosis is one of the first pieces of information requested. The next set of questions are very important to your workers’ compensation claim. They ask the doctor if it is their belief that the job duties at work either caused or aggravated your injury.
The next few items inquire about any additional medical conditions that the employee may already have that are affected or worsened by the new injury, what the treatment plan for the work place injury is and whether any medications prescribed for the injury may affect judgment or ability to perform certain jobs. If the employee is able to return to work doing the same job as before the injury occurred, the next two items on the questionnaire are not necessary and the physician is instructed to skip to the last question. If the employee is not able to return to work at the same job description, the physician must provide the restrictions that will be needed when the employee returns to work and how long the restrictions will be necessary.
The questions that are included in the medical status questionnaire are the only items that are allowed to be asked by the employer or insurance provider directly to the physician. The employer or their insurance providers are not required to ask all of the questions that are included on the form. There is a place for them to check which items they need to be addressed, which may or may not be all questions on the form. They also do not have to have permission from you (as the employee) to have the physician fill out this form, as stated in North Carolina General Statute Section 97-25.6 (c)(2). Once the form is filled out, the physician must provide the responses to the employer or their insurance provider and the employee and his or her attorney or other representative.
Key Takeaways
- The questionnaire is the only form an employer or insurer is permitted to use when communicating directly with your treating physician about your injury.
- Your employer does not need your permission to request that your doctor complete this form under NC General Statute Section 97-25.6(c)(2).
- The physician is required to send completed responses to both the employer or insurance provider and to the employee and their attorney or representative.
- Key questions on the form ask whether your job duties caused or aggravated your injury — answers that can significantly affect your workers' compensation claim.
- If you can return to your same job without restrictions, the physician may skip the sections about work limitations.
- The employer or insurer may choose to have only specific questions answered; they are not required to ask every item on the form.
Attorney Insight
The question I see catch injured workers off guard most often is the one asking whether their job duties "caused or aggravated" the injury — because that answer can directly determine whether a claim is accepted or contested. Employers and insurers get to send this form to your doctor without telling you first, and by the time you see the responses, the damage to your claim may already be done. If you have an attorney, make sure they're in the loop before your physician starts filling out any paperwork — having your representative's name on file ensures you receive a copy of the completed form at the same time the insurer does.
