INSTRUCTIONS: Each executive officer having an ownership interest in a for submission with the Corporation's Application for Executive Officer Exception. INSTRUCTIONS: If not filing electronically, submit one original application for the corporation along with an Executive. Officer's Declaration for every officerQuick Reference Guide to LIBC Forms. BWC Forms 9, Workers' Compensation Medical Report Form 14, Instructions for Religious Exception Application. The LIBC-9 form and required accompanying Listed on the reverse are guidelines for the completion of billing forms and submission of records. WORKERS' WORKERS' COMPENSATION MEDICAL REPORT FORM If the employer is covered by an insurer, the bill is to be sent to the insurer. The LIBC-9 form and required accompanying documentation shall be submitted within ten (10) days of commencing treatment and at least once a month thereafter, as long as treatment continues. For further instructions and helpful hints on using interactive forms, click here. 9/07. EMPLOYER/INSURANCE CARRIER FORMS, Doc #, Word, PDF acrobat 9-1. Employer's Light Duty Return to Work Form 9-3. LIBC-14. Instructions for Religious Exception Application The Medical Report Form, LIBC-9, is a form prescribed by the Bureau. Regulation Section 127.203(a) states: Providers who treat injured employees are required to submit periodic medical reports to the employer, commencing 10 days after treatment begins and at least once a month thereafter as long as treatment continues. Fill Pdf Libc 9 Form, download blank or editable online. WITH THE EMPLOYER OR INSURER ACCORDING TO INSTRUCTIONS PROVIDED ON THIS FORM. Completed LIBC-9 Forms for each date of service. of The Doctor's Guide to Pennsylvania Workers' Compensation Billing by following the instructions below.