Medical Treatment Statement for Workers' Compensation - Wisconsin 2026

1. Click ‘Get Form’ to open the Medical Treatment Statement in our editor.
2. Begin by entering the WC Claim Number at the top of the form. This is essential for tracking your claim.
3. Fill in your personal details, including Employee Name and Social Security Number. Ensure accuracy to avoid delays.
4. Next, provide the Employer Name and Injury Date. This information helps establish the context of your claim.
5. Indicate the Insurance Company Name responsible for your coverage during this period.
6. List the Names of Providers who administered treatment, medication, or supplies related to your injury.
7. In the charges section, detail Total Charges incurred, Amount Paid By Applicant, Amount Paid By Other Insurance Carriers (including their names), and any Unpaid Balance.
8. Attach an itemized statement for each expense claimed as required by law and ensure it is submitted at least 15 days before any hearing.

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