Resources

Workers' compensation

• Confidential request for ownership information
• Employer's report of wages
• Encova Edge system admin form for insureds
• Job analysis form
• Job function evaluation form
• Return-to-work booklet
• Return-to-work notice
• West Virginia Encova Select employer manual

• Adjustment/correction request
• Attending Physician's report
• Audiology report
• Diagnosis update
• Encova Edge system administrators form for vendors
• Grievance form(West Virginia Managed Care plan)
• In-home nursing/attendant care log
• Low back examination
• Notice of maximum medical improvement
• Physician statement of physical capabilities
• Physician's report of occupational pneumoconiosis
• Physician's roentgenographic interpretation report of occupational pneumoconiosis
• Request for independent medical examination
• Service invoice
• West Virginia Encova Select provider manual

Workers' compensation

• Change of address notification
• First fill form - English
• First fill form - Spanish
• Grievance form (West Virginia Managed Care plan)
• Medical records release
• Pharmacy invoice
• Request for change of physician
• Request for file copies
• Routine claimant travel voucher
• Specialty claimant travel voucher
• West Virginia Encova Select employee manual