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

Each insurer is required to submit their treating provider list to DIR/WCS per NRS 616C.087(6)
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 http://ada.nv.gov/home/Overview_ADA/
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
Direct further questions and concerns to kgodwin@dir.nv.gov