Chiropractic Services
For subsequent medical treatment the Capability Assessment form (C3) form needs to be completed.
This information will assist employers in determining appropriate accommodations.
Keeping a worker on the job in transitional duty reduces the worker’s likelihood of long-term disability.
Please return the original form to WSI, provide a copy for the injured worker to give to their
employer, and retain a copy for your records.
Completion of the C3 is not a substitute for chart notes.
Notes (e.g., SOAP format) are needed for continued management of the
claim as well as for payment of services. All medical documentation,
including the C3 forms, should continue to be faxed to 1-888-786-8695 or 1-701-328-3820.
Providers may call WSI Customer Service at 1-800-777-5033 to obtain a supply of the C3 forms.
The C3 form cannot be used to file a claim.
When treatment has been completed and the patient has reached maximum medical
improvement the Chiropractic Progress/Final Report (C25) will need to be completed.
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