DWC legacy forms
Access To Public Records
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
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
Judicial Ethics Forms
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