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 9/13/23)
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

Requirements for Joining the Rating Panel NAC 616C.021
Have three years or more of experience in industrial health in private practice as a physician or chiropractic physician.
Take one course on the American Medical Association's Guides to the Evaluation of Permanent Impairment (AMA Guides) 5^th Edition. Approved courses are available from the American Board of Independent Medical Examiners (ABIME) and the American Academy of Expert Medical Evaluators (AAEME).
Pass two examinations, including:
- An examination provided by ABIME on the AMA Guides 5^th Edition; and
- The Nevada Impairment Rating Skills Assessment Test which is administered by AAEME. New raters must take the version of the test provided on 12/10/2023 or later.
Submit the Rating Panel Application
Upon review by the Medical Unit that all the requirements above are met, you will be invited to attend a course provided by the Division of Industrial Relations on the following topics:
- Nevada statues and regulations related to the evaluation of permanent partial disabilities; and
- Form D-9(c) Permanent Work-Related Mental Impairment Rating Report Work Sheet

Each insurer is required to submit their treating provider list to DIR/WCS per NRS 616C.087(6) by October 1st of each year.
Insurers are required to submit provider lists to DIR/WCS per NRS 616C.087(6); provider lists will only be accepted when submitted by insurers (not TPAs)
Each list must be certified by a claims adjuster licensed pursuant to NRS 684A per NRS 616C.087(6)
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
Provider lists must be emailed to medpanels@dir.nv.gov
- Include the insurer's name and that a provider list(s) are attached in the subject line. This will ease identification and expedite processing.
CARDS functionality that allows the insurers to enter their treating provider lists directly is not currently available. This functionality is estimated to go live in June 2025. WCS will communicate with insurers and TPAs when these functions are available, providing the due date to enter treating provider lists, and providing scheduled training.