Psychiatric or Psychological Report Certification of Confidentiality - West Virginia 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Claimant Name, Claim Number, and SSN in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in the Date of Injury (DOI) and Date of Evaluation (DLE) to provide context for the report.
4. In the section regarding report authorship, input the Report Author's name and Date of Report along with the number of pages in the full report.
5. Similarly, complete the Summary Author's details, including their name, date, and page count for the summary document.
6. Indicate any relevant protest information related to the Division’s Order by filling out that section appropriately.
7. Finally, certify compliance with W.Va. Code §23-1-13(f) by signing and dating at the bottom of the form before submission.

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