The  purpose behind the Montana Department of Labor and Industry (DLI) Medical Status Form is to evaluate an injured workers return to the workplace. It is a communication tool between a physician, injured worker, and the employer that outlines the current work abilities of the injured worker and whether they return on a part or full-time basis.

By law, the treating physician or designee must complete the form after each visit. This practice gives the insurer the information they need to handle the claim properly and pay any benefit entitlement promptly. 

When the provider fills out the form, it should eliminate requests for the same information from the insurer. However, if the insurer asks the provider to answer the same questions outlined on the sent Medical Status Form, the provider may bill the insurer for their time. In addition, providers may bill insurers who ask for more information not contained in the DLI form. Providers should use code MT001.

The form and instructions are available on MSF’s webpage  or on DLI’s site. You may also request a duplicate hard copy free of charge from DLI. Contact Celeste Ackerman at 406-444-6543 or celeste.ackerman@mt.gov. 

Medical providers also have permission to have the form programmed into their medical records system if the name of the form still is the same and all the data fields are included in the same order as DLI’s form. Insurers and medical providers have requested a universal form that is easily recognized by all stakeholders.