These forms are to be completed and filed on all claims.

• First Notice of Loss
  This form is required by the Mississippi Workers’ Compensation Commission and must be filed on all claims. It is often referred to as the B-3 form.
• MSBA First Report of Injury or illness
  This form collects all of the required information for the B-3 but gives more room to write and is more user friendly. Either this form or the First Notice of Loss form above can be completed and submitted directly into the CorVel CareMC claims system.
• Witness Statement*
  This form may be used if there is a witness(es) to the incident. Information on the form helps the adjuster in investigating the claim.
• HIPAA Authorization*
  This form must be signed so that the adjuster can get copies of the medical records and pay any bills MSBA is responsible for paying.
• Notice of Physician Choice*
  The form gives notification of the doctor chosen by the employee to render treatment.
• WC Exam and Work Status*
  This form goes with the employee to the doctor. It has a section to be completed by the doctor regarding work status.
• Pharmacy First Fill Form
  This form allows an employee to receive a 14 day supply of medications with no out-of-pocket expense or co-pays. Injured employees should take this form with them to the pharmacy when filling their first prescription.

*These forms must be completed and faxed
to CorVel at 1-866-434-4720.