A copy of this form must be provided to the employee or the employee's attorney of record if any.
Medical providers: please return the completed form to the carrier.
Each rated body part: is employee at maximum medical improvement? Was employee released with restrictions?
Hearing: please attach audiograms and calculations of hearing loss.
Carriers: file via electronic document filing portal.
| Question | Answer |
|---|---|
| Form Name | Form 25R |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 59 |
| Avg. time to fill out | 10 min |
| Edition | 05/2017 |
| Issuing agency | North Carolina Industrial Commission |
| Where to send | Medical providers return the completed form to the carrier |
| Matches the agency's file | Yes, checked October 4, 2026 |
| Other names | Form 25R, 25R, NC Form 25R, Evaluation for Permanent Impairment |
| Official source | Form 25R (Rev 05/2017), North Carolina Industrial Commission |
Form 25R isn’t the one you’re looking for?