Agents
Policyholders
Workers' compensation
- WC-5259 06-21 AUTOMATIC CLEARING HOUSE TRANSFER APPLICATION
- CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION
- WC-5243 6-20 ELECTRONIC FUNDS TRANSFER OPT-OUT AND ADJUSTMENT
- WC-5244 6-20 EMPLOYER’S REPORT OF WAGES
- WC-5245 6-20 JOB ANALYSIS FORM
- WC-5246 6-20 JOB FUNCTION EVALUATION FORM
- WC-5247 6-20 RETURN-TO-WORK NOTICE
- WC-5248 09-20 ENCOVA EDGE SYSTEM ADMIN FORM FOR INSUREDS
- WC-5167-BK 7-20 RETURN-TO-WORK BOOKLET
- WC-5211-MN 07-20 WEST VIRGINIA ENCOVA SELECT EMPLOYER MANUAL
Medical providers
- WC-5227 6-20 ADJUSTMENT/CORRECTION REQUEST
- WC-5228 6-20 ATTENDING PHYSICIAN’S REPORT
- WC-5229 6-20 AUDIOLOGY REPORT
- WC-5230 6-20 DIAGNOSIS UPDATE
- WC-5231 6-20 GRIEVANCE FORM (WEST VIRGINIA MANAGED CARE PLAN)
- WC-5232 6-20 IN-HOME NURSING/ATTENDANT CARE LOG
- WC-5233 6-20 LOW BACK EXAMINATION
- WC-5234 6-20 NOTICE OF MAXIMUM MEDICAL IMPROVEMENT
- WC-5235 6-20 PHYSICIAN STATEMENT OF PHYSICAL CAPABILITIES
- WC-5236 6-20 PHYSICIAN’S REPORT OF OCCUPATIONAL PNEUMOCONIOSIS
- WC-5237 6-20 PHYSICIAN’S ROENTGENOGRAPHIC INTERPRETATION REPORT OF OCCUPATIONAL PNEUMOCONIOSIS
- WC-5258 6-20 REQUEST FOR INDEPENDENT MEDICAL EXAMINATION
- WC-5239 6-20 SERVICE INVOICE
- WC-5240 09-20 ENCOVA EDGE SYSTEM ADMINISTRATORS FORM FOR VENDORS
- WC-5212-MN 11-20 WEST VIRGINIA ENCOVA SELECT PROVIDER MANUAL
Claimants
Workers' compensation
- WC-5249 6-20 CHANGE OF ADDRESS NOTIFICATION
- WC-5250 6-20 CLAIMANT TRAVEL VOUCHER
- FIRST FILL FORM - ENGLISH
- FIRST FILL FORM - SPANISH
- WC-5252 6-20 GRIEVANCE FORM (WEST VIRGINIA MANAGED CARE PLAN)
- WC-5253 6-20 MEDICAL RECORDS RELEASE
- WC-5254 6-20 PHARMACY INVOICE
- WC-5255 6-20 REQUEST FOR CHANGE OF PHYSICIAN
- WC-5256 6-20 REQUEST FOR FILE COPIES
- WC-5210-MN 06-21 WEST VIRGINIA ENCOVA SELECT EMPLOYEE MANUAL