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)
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
Direct further questions and concerns to kgodwin@dir.nv.gov