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Good Morning
10:51:17 AM CDT
Sunday, April 20, 2014

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Chiropractic Services

Topics Palliative Care Requirements Forms & Publications Provider Request for Adjustment (M6) form
General Information Documentation Requirements First Report of Injury (FROI) Form Chiropractic Progress/Final Report (C25)
Chiropractic Treatment Window Subsequent Treatment Capability Assessment form (C3) Utilization Review Chiropractic Request (UR-Chiro)
Authorization Process   Medical Services Dispute Resolution Request (M2) Quick Tips for Chiropractors

Subsequent Treatment

For continued medical treatment, the Capability Assessment form (C3) form needs to be completed to address any limited capabilities. This information assists the employers in determining appropriate accommodations.

Please return the original C3 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 form 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. Additionally, the 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) should be completed.

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