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 64 State Forms found

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Employee Expense Form

 WCB-206 (eff. 10/1/15, rev. 12/42/23)

COMPLAINT FOR PENALTIES PURSUANT TO 39-A 205(3)

 WCB-400 (eff. 2/1/17)

COMPLAINT FOR PENALTIES 39-A 205(4)

 WCB-410 (eff. 2/1/17)

PETITION FOR FORFEITURE PURSUANT TO 39-A 324(2)

 WCB-420 (eff. 2/1/17)

MEDICAL FEE SCHEDULE JANUARY 1, 2020

 90-351 EFFECTIVE: JANUARY 1, 2020

Limited Release of Medical/Health Care Information Related to Psychological Matters

 WCB-220-A (eff 09/04/2023, rev 10/23/2023)

Limited Release of Medical/Health Care Information Related to Substance Use Disorder

 WCB-220-B (eff 09/04/2023, rev 10/23/2023)

Limited Release of Medical/Health Care Information Related to HIV/AIDS and Sexually Transmitted Diseases

 WCB-220-C (eff 09/04/2023, rev 10/23/2023)

Revocation of Limited Release of Medical/Health Care Information

 WCB-220-R (eff 09/04/2023, rev 10/23/2023)

PETITION TO TERMINATE BENEFIT ENTITLEMENT

 WCB-211 eff. 9/1/18

WORK SEARCH RECORD

WCB-205 eff. 9/1/18

EMPLOYMENT REHABILITATION PROVIDER APPLICATION PURSUANT TO 39-A M.R.S.A. 217

 WCB-319 (eff. 03/10/20)

DISCONTINUANCE OF COMPENSATION

 WCB-4D (effective 04/01/2025)

MEDICAL FEE SCHEDULE JANUARY 1, 2024

 90-351 EFFECTIVE: JANUARY 1, 2024

JOINT SCHEDULING MEMORANDUM

 No Form Number No Form/Rev Date
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