The treating physician completes this form to provide information to support an injured worker’s claim which resulted in amputation to the foot, toes (phalanges) or metatarsals.
The physician should complete this form with a straight line drawn at the exact point of amputation. Circles are not acceptable. This will allow the Commission to determine an accurate entitlement of permanent partial disability benefits.
This form may be filed electronically through the Commission’s WebFile system at http://webfile.workcomp.virginia.gov. To file electronically, the user must have a valid and active WebFile account. This form may be filed by mail or in-person at 333 E. Franklin St., Richmond, VA 23219. This form may also be filed by fax 804-823-6956.
For questions or assistance with completing this form, please contact the Virginia Workers’ Compensation Commission toll free at 1-877-664-2566 or by email at Questions@workcomp.virginia.gov.