Medical Providers

Revised C-4 Form & Discontinued C-4A eff 9/13/23

C-4 Form Employee's Claim for Compensation - Report of Initial Treatment - Fillable (eff 2/2025)
C-4A Form Release of Medical and Other Information For Nevada Workers’ Compensation Claims (8/21) - Discontinued eff 9/13/23
Instructions for using Form C-4A - Discontinued eff 9/13/23

Note: Asterisk (*) beside provider name denotes telemedicine provider only

Each insurer is required to submit their treating provider list to DIR/WCS per NRS 616C.087(6) as amended by SB317 – on or after September 1 and on or before October 1 of each year.
The treating provider list should include the providers of mental health care required by NRS 616C.180. Insurers are not required to submit the list providers of mental health care separately.
Per NRS 616C.087(6), a third-party administrator may file a single list on behalf of more than one insurer for which the administrator provides services, if the list expressly indicates each insurer to which the list applies.
List Certification

Each list must be certified by a claims adjuster licensed pursuant to NRS 684A per NRS 616C.087(6); or
If an insurer uses only salaried employees to investigate, negotiate and settle workers’ compensation claims as described in subsection 4 of NRS 684A.040 and is not required to employ adjusters licensed pursuant to chapter 684A of NRS, the list must be signed and certified as accurate by the insurer’s highest ranking employee who is responsible for processing workers’ compensation claims filed in this State. See R076-23 Sec. 9.

Insurers are requested to submit provider lists which are ADA compliant. For more information, see https://ada.nv.gov/ .
Provider lists must be submitted in PDF format. Include the name and license number of the certified adjuster or the highest-ranking employee responsible for processing workers’ compensation claims in this state if exempt and include the date of submission.
Provider lists must be emailed to medpanels@dir.nv.gov
Include the insurer's name and that provider list(s) are attached in the subject line. This will ease identification and expedite processing. The submission date should be included on the list.
Direct further questions and concerns to medpanels@dir.nv.gov