Access To Public Records

• Request For Authorization Number Form_DWC-AD3.pdf
• Request For Public Records.pdf

Administrative Forms

• Arbitrator Application.pdf
• Arbitrator Submittal Form_DWC-10297.pdf
• Doctor's First Report Of Occupational Injury Or Illness_DLSR-5021.pdf
• EDEX Client Acknowledgement.pdf
• EDEX Client List.pdf
• EDEX Subscriber Agreement Application.pdf
• Employer's Report Of Occupational Injury Or Illness_DLSR-5020.pdf
• Notice Of Employee Death_DIA-510.pdf
• Notice To Employees Poster_DWC-7.pdf
• Official Medical Fee Schedule Order Form.pdf
• Physician's Guide Order Form.pdf
• Request For Accommodations By Persons With Disability_DWC-5.pdf

Audit Forms

• Annual Report Of Adjusting Location For Claims Adminstrators_DWC-852.pdf
• Audit Referral Form_DWC-AU906.pdf
• Audit Report Of Inventory 2011_DWC-851.pdf
• How To File A Complaint With The Audit Unit_DWC-AU905.pdf

Carve Out Agreement Forms

• Petition For Permission To Negotiate A Section 3201.7 Labor-Management Agreement_DWC-RSG1.pdf

Claim And Court Forms

• Appeal From Determination And Order Of The Rehabilitation Unit.pdf
• Application For Adjudication Of Claim (Death Case)_DIA-2.pdf
• Application For Benefits For Serious And Willful Misconduct Of Employer.pdf
• Application For Discrimination Benefits Pursuant To Labor Code Section 132(A).pdf
• Declaration Pursuant To Labor Code Section 4906(g).pdf
• I&A Guide 11.pdf
• Information Guidelines For Submission Of Settlement Documents.pdf
• Medical Mileage Expense_1-1-07.pdf
• Medical Mileage Expense_1-1-08.pdf
• Medical Mileage Expense_1-1-09.pdf
• Medical Mileage Expense_1-1-10.pdf
• Medical Mileage Expense_1-1-11.pdf
• Medical Mileage Expense_7-1-06 to 1-1-07.pdf
• Medical Mileage Expense_7-1-08.pdf
• Notice Of Dismissal Of Attorney_DWC-37.pdf
• Notice Of Employee Death_DIA-510.pdf
• Objection To Treating Physician's Recommendation For Spinal Surgery_DWC-233.pdf
• Petition For Appointment Of Guardian Ad Litem And Trustee_DWC-8.pdf
• Petition For Change Of Primary Treating Physician_DWC-280.pdf
• Petition For Commutation Of Future Payments_DWC-49.pdf
• Petition For Reconsideration_DWC-45.pdf
• Petition To Reopen_DWC-42.pdf
• Pre-Trial Conference Statement_DWC-10253.1.pdf
• Special Notice Of Lawsuit.pdf
• Substitution Of Attorneys_WCAB-36.pdf
• Workers' Compensation Claim Form_DWC-1.pdf

Complaint Forms

• How To File A Complaint With The Audit Unit_DWC-AU905.pdf
• Qualified Medical Evaluator Complaint Form.pdf
• Utilization Review Complaint Form_DWC-UR1.pdf

Disability Evaluation Forms

• Apportionment_DEU-105.pdf
• Employee's Request For Informal Permanent Disability Rating_DEU-200.pdf
• Notice Of Options Following Disability Rating (Spanish)_DEU-110.pdf
• Notice Of Options Following Disability Rating_DEU-110.pdf
• Request For Informal Rating (By Insurance Carrier Or Self-Insurer)_DEU-201.pdf

Fraud Reporting Forms

• Report Of Suspected Medical Care Provider Fraud_DWC-SMBFR1115.pdf

Judicial Ethics Forms

• Complaint Form And Information.pdf

MPN Forms

• Cover Page For Medical Provider Network Application_DWC-9767.4.pdf
• Independent Medical Review Application (Spanish)_DWC-9768.10.pdf
• Independent Medical Review Application_DWC-9768.10.pdf
• Notice Of Medical Provider Network Plan Modification Labor Code 9767.8_DWC-9767.8.pdf
• Physician Contract Application_DWC-9768.5.pdf
• Sample Initial Written Employee Notification Re. Medical Provider Network (Spanish).pdf
• Sample Initial Written Employee Notification Re. Medical Provider Network.pdf

Pre-Designation Of Personal Physician_Change Of Physician Forms

• Notice Of Personal Chiropractor Or Personal Acupuncturist (Spanish)_DWC-9783.1.pdf
• Notice Of Personal Chiropractor Or Personal Acupuncturist_DWC-9783.1.pdf
• Notice Of Pre-Desgination Of Personal Physician_DWC-9783.pdf
• Notice Of Pre-Designation Of Personal Physician (Spanish)_DWC-9783.pdf

Primary Treating Physician Forms

• Primary Treating Phsycian's Permanent And Stationary Report_DWC-PR3.pdf
• Primary Treating Physician's Permanent And Stationary Report_DWC-PR4.pdf
• Primary Treating Physician's Progress Report_DWC-PR2.pdf

QME And AME Forms

• Additional Panel Request_QME-31.7.pdf
• AME Or QME Declaration Of Service Of Medical - Legal Report_QME-122.pdf
• Application For Accreditation Or Re-Accreditation As Educaiton Provider_QME-118.pdf
• Application For Accreditation Or Re-Accreditation As Education Provider Instructions.pdf
• Application For Appointment As Qualified Medical Evaluator_QME-100.pdf
• Declaration Regarding Protection Of Mental Health Records_QME-121.pdf
• Faculty Disclosure Of Commercial Interest_QME-119.pdf
• QME Appointment Notification Form_QME-110.pdf
• QME Disclosure Of Specified Financial Interests_QME-124.pdf
• QME Notice Of Unavailability_QME-109.pdf
• QME Or AME Conflict Of Interest Disclosure Form And Objection Or Waiver Instructions.pdf
• QME Or AME Conflict Of Interest Disclosure Form And Objection Or Waiver_QME-123.pdf
• QME_AME Report Time Fram Extension Request_QME-112.pdf
• Qualified Medical Evaluator's Findings Summary Form (Unrepresented Cases Only)_QME-111.pdf
• Reappointment Application As Qualified Medical Evaluator_QME-104.pdf
• Registration For QME Competency Examination_QME-102.pdf
• Replacement Panel Request_QME-31.5.pdf
• Request For QME Panel Under Labor Code Section 4062.1 - Unrepresented (Spanish)_QME-105.pdf
• Request For QME Panel Under Labor Code Section 4062.1 - Unrepresented Attachment.pdf
• Request For QME Panel Under Labor Code Section 4062.1 - Unrepresented_QME-105.pdf
• Request For QME Panel Under Labor Code Section 4062.2 - Represented Attachment.pdf
• Request For QME Panel Under Labor Code Section 4062.2 - Represented_QME-106.pdf
• Voluntary Directive For Alternate Service Of Medical-Legal Evaluation Report On Disputed Injury To Psyche_QME-120.pdf

Spinal Surgery Second Opinion Forms

• Application For Spinal Surgery Second Opinion Physician List_DWC-232.pdf
• Objection To Treating Physician's Recommendation For Spinal Surgery_DWC-233.pdf

Utilization Review Forms

• Utilization Review Complaint Form_DWC-UR1.pdf