M1 workers comp form 2026

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The document is a Practitioner’s Report for the State of Maine Workers' Compensation Board, used to assess an employee's work-related injury. It includes sections for practitioner details, patient information, diagnosis, treatment plans, work capacity, and follow-up dates. The report aims to determine if the injury is work-related, outline treatment recommendations, and evaluate the employee's ability to return to work.

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Click ‘Get Form’ to open the m1 workers comp form in the editor.
Begin by filling in the 'Employer Name' and 'Employee Last Name' fields. Ensure accuracy as this information is crucial for processing.
Next, provide the 'Employer Mailing Address & Phone #' along with the 'Insurer Name' and 'Insurer Mailing Address'. This helps in identifying responsible parties.
Indicate the 'Date of Injury' and select the type of practitioner by circling MD, DO, or DC as applicable.
In the 'Patient's Complaints' section, detail any issues faced by the employee. Include relevant ICD-9 codes if available.
Complete the treatment plan section, specifying whether treatment will continue and any medications prescribed that may affect work capacity.
Finally, ensure to sign and print your name along with your contact details before submitting the form.

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