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Medical Treatment Guidelines Forms

New Medical Treatment Guideline forms have been introduced with the implementation of 2013 MTG Addition and Improvements (in March 2013). 

Forms are in PDF format. The Board recommends using the latest version of Adobe Reader Link to External Website which is available as a free download from Adobe's web site.

After the form opens in your browser, you may complete the form by typing information on the form before you print it.

IMPORTANT: Two-sided and multi-page forms are to be printed and submitted to the Board in duplex format. If this is not possible, submit as separate sheets. However, do NOT submit to the Board any sheets that contain only instructions and/or reference material. Parties of interest other than the Board must receive both sides of all two-sided forms and all pages of multi-page forms.

If you require assistance with these forms, please contact the WCB Medical Director's Office at 1-800-781-2362.

Medical Treatment Guidelines Form Revisions Summary (March 2013) adobe pdf

Medical Treatment Guidelines Forms Effective March 1, 2013
Form Number /
Version Date
Form Title Who Files Where to File When to File
MG-1 (2-13) Attending Doctor's Request for Optional Prior Approval and Carrier's/Employer's Response Health Care Provider Workers' Compensation Board and Insurance Carrier Request confirmation from the Insurance Carrier that the procedure or test is based on a correct application of the Medical Treatment Guidelines.
MG-1.1 (2-13) Continuation to Form MG-1, Attending Doctor's Request for Optional Prior Approval Health Care Provider Workers' Compensation Board and Insurance Carrier Request confirmation from the Insurance Carrier that more than one procedure or test is based on a correct application of the Medical Treatment Guidelines.
MG-2 (2-13) Attending Doctor's Request for Approval of Variance and Carrier's Response Health Care Provider Workers' Compensation Board, Insurance Carrier, Injured Employee and his/her representative To request testing or treatment that is outside or exceeds the Medical Treatment Guidelines.
MG-2.1 (2-13) Continuation to Form MG-2, Attending Doctor's Request for Approval of Variance Health Care Provider Workers' Compensation Board, Insurance Carrier, Injured Employee and his/her representative To request more than one test or treatment that is outside or exceeds the Medical Treatment Guidelines.
C-4 AUTH (2-13) Attending Doctor's Request for Authorization and Carrier's Response Health Care Provider Insurance Carrier/Self-Insured Employer, with a copy to the Workers' Compensation Board. If the patient is represented by an attorney or licensed representative send a copy to such legal representative. If the patient is not represented, a copy must be sent to the patient. This form is used to confirm a telephone request for written authorization for special service(s) costing over $1,000 in a non-emergency situation.
C-8.1 (2-13) Notice of Treatment Issue/Disputed Bill Insurance Carrier/Board-approved self-insurer Workers' Compensation Board, copy to employee and his/her representative, and health provider. Treatment issue: within 5 days after terminating medical care or refusing authorization.

Disputed bill: within 45 days of submission of bill.