Workers' Compensation Forms

Welcome to the department's Workers' Compensation LIBC Forms. The form hyperlinks are designed to provide a resource, but not supersede any statuary or regulatory requirements relating to form filing. When a copy of a form is required by law, to be provided to another party, a true and correct copy of such information must be provided to that party consistent with the act, regulations and/or any applicable department-issued policy statement or written guidance.

The workers' compensation forms are for your immediate use. However, the Bureau of Workers' Compensation and the Workers' Compensation Office of Adjudication require their use on the effective/revision dates noted. Previous versions of these forms submitted after the revision date will not be accepted and will be returned to the filing party.

Bureau of Workers' Compensation Forms
Workers' Compensation Office of Adjudication Forms
Workers' Compensation Appeal Board Forms

Detailed filing instructions may be found under Claims Information.

We encourage you to submit answers to petitions through WCAIS. You may also submit them directly to the workers' compensation judge assigned to the case.

The following EDI Release 3 crossover documents are being provided to assist with the implementation of Claims EDI Release 3 filing requirements. Submit any comments, questions and suggestions you have regarding the guide to the Bureau’s EDI section via the Customer Service “Submit a Question” feature from the WCAIS Dashboard.

Note: Please continue to check for the posting of additional scenarios/revisions.

The following EDI Forms Solution Data Element (DN) Mapping reference documents are being provided to assist filers with determining the appropriate EDI fields to populate to ensure accuracy in form filing.

EDI Claims Implementation Guide

The Bureau of Workers' Compensation has published the Electronic Data Interchange (EDI) Claims Implementation Guide and its supporting documents. This version of the guide provides technical information, procedures and explanations to help claims administrators prepare and navigate future EDI processes.

Submit any comments, questions and suggestions you have regarding the guide to the bureau’s EDI section via the Customer Service “Submit a Question” feature from the WCAIS Dashboard. We will consider your input as we make revisions to it in the future.

The PA Workers' Compensation Act gives employers the right to establish a list of designated health care providers. When the list is properly posted, injured workers must seek treatment for the work injury or illness with one of the designated providers for 90 days from the date of the first visit. There are some specific guidelines provided in the rules and regulations for these lists:

• The employer must provide a clearly written notice to employee of the employee's rights and duties.
  
  
• The notice must be signed by the employee at the time of hire, whenever changes are made in the list and at the time of injury.
  
  
• The list must contain at least six providers; three of the six providers must be physicians.
  
  
• Providers as defined in the Act are more than just physicians.
  
  
• Each provider's name, address, telephone number and specialty must be included on the list.
  
  
• If a particular specialty is not on the list and the specialty care is reasonable and necessary for treatment of the work injury, the employee will be allowed to treat with a health care provider of his or her choosing. Martin v. WCAB (Emmaus Bakery), 652 A.2d 1301 (Pa. 1995)
  
  
• The employer may not direct the employee to any specific provider on the list.
  
  
• The employee may switch from one designated provider to another designated provider.
  
  
• Listed providers must be geographically accessible.
  
  
• Listed providers must contain specialties appropriate for the anticipated work-related medical problems of the employee.
  
  
• If employer's list of designated providers fails to comport with the Act and the regulations, the employee has the right to treat with a provider of his or her choice

More details regarding Employers Panel Provider Requirements.

Further details are contained in Subchapter D, Sections 127.751 through 127.755 of the rules and regulations found on page 196 of the Workers' Compensation Act. The Act is available online here.