Treating an Injured Worker
For subsequent medical treatment the
Capability Assessment form (C3)
form must be completed. This information will assist employers in
determining appropriate accommodations. Keeping a worker on the job
in transitional duty reduces the worker’s likelihood of long-term disability.
Please return the original 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 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.
All medical documentation, including the C3 forms, should continue to be faxed to
1-888-786-8695 or 1-701-328-3820. Providers may call WSI Customer Service at
1-800-777-5033 to obtain a supply of the C3 forms. The C3 form cannot be used to
file a claim.
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