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Forms

Forms in this section:

EAMS OCR forms Independent Bill Review - IBR
Legacy forms Independent Medical Review - IMR
Administrative forms Judicial ethics forms
Claim and court forms Lien filing and activation fees
Access to public records Medical provider network - MPN
Audit forms Pre-designation of personal physician / Change of physician forms
Carve out agreement forms Primary treating physician forms
Complaint forms Qualified medical evaluator - QME and agreed medical evaluator - AME
Disability evaluation forms Supplemental Job Displacement Benefit - SJDB
Fraud reporting forms Utilization review forms
EAMS OCR forms - Court administrator forms Number Samples
Compromise and release - dependency claim fillable image DWC-CA 10214-d
Compromise and release fillable image DWC-CA 10214-c Sample
Compromise and release - third party fillable image DWC-CA 10214-e
Declaration of readiness to proceed - expedited trial 4/2014 fillable image DWC-CA 10208. 3  
Declaration of readiness to proceed 6/2011 fillable image DWC-CA 10250.1 Sample
Document cover sheet 8/2/2010 fillable image
Body part codes list 11/17/08
Proof of service fillable image
DWC-CA 10232.1

Sample

Document separator sheet fillable image
- click paperclip for document titles and document types 7/2014

Changes to document separator sheet
Document titles list 7/2014 excel image

DWC-CA 10232.2
Lien conference disposition fillable image WCAB 27
Stipulations with request for award - death casefillable image DWC-CA 10214-b

Stipulations with request for award DOI post 1/1/2013 4/2014 fillable image
For injury on or after 1-1-2013

Stipulations with request for award fillable image
For injury prior to 1-1-2013

DWC-CA 10214-a

 

 

Sample

Supplement to minutes of hearing fillable image WCAB 20.1
EAMS OCR forms - Workers' Compensation Appeals Board forms Number Samples
Application for adjudication of claim fillable image
How to submit an amended application for adjudication of claim
WCAB 1 Sample
Sample
Answer to application for adjudication of claim 11/17/08 fillable image WCAB 10 Sample
Notice and request for allowance of lien 11/17/08 fillable image WCAB 6 Sample
Petition to terminate liability for temporary disability indemnity 11/17/08 fillable image WCAB 46 Sample
EAMS OCR forms - Disability Evaluation Unit - DEU forms Number Samples
Employees permanent disability questionnaire 11/17/08 fillable image En español DWC-AD 100
Request for consultative rating - RCR 11/17/08 fillable image DWC-AD 104 Sample
Request for reconsideration of summary rating by the administrative director
11/17/08 fillable image
DWC-AD 103
Request for summary rating determination of QME's report
4/19/2010 fillable image
DWC-AD 101 Sample
Request for summary rating determination - primary treating physician report
11/17/08 fillable image
DWC-AD 102 Sample
EAMS OCR forms - Uninsured Employers Benefits Trust Fund/Subsequent Injuries Benefits Trust Fund forms Number
Application for discretionary payments from the Uninsured Employers' Fund
11/17/08 fillable image
DWC-UEF 50
Application for Subsequent Injuries Fund benefits 11/17/08 fillable image

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Legacy forms Number
Administrative forms Number
Arbitrator application fillable image DWC-CA 10297
Arbitrator submittal 11/17/08 fillable image  
Doctor's first report of occupational injury or illness acrobat image DLSR 5021
EDEX client acknowledgment of legal constraints on access to information and use of information fillable image
EDEX client list fillable image
EDEX subscriber application fillable image
Employer's report of occupational injury or illness fillable image DLSR 5020
Notice to employees poster - English and Spanish - 10/8/2010 fillable image DWC 7
Official medical fee schedule order form acrobat image
Physician's guide order form fillable image
Request for accommodations by persons with disability fillable image DWC 5

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Claim and court forms Number Samples
Addendum to application for adjudication of claim to identify legal entity employing injured worker fillable image WCAB 2
Appeal from determination and order of the Rehabilitation Unit fillable image
Application for adjudication of claim - Death case fillable image DIA 2
Application for benefits for serious and willful misconduct of employer fillable image
Application for discrimination benefits pursuant to Labor Code section 132 - A - Sample
Attorney fee disclosure statement fillable image DWC 3
Declaration pursuant to Labor Code section 4906 - g fillable image
Information guidelines for submission of settlement documents acrobat image

Medical mileage expense form in English/Spanish fillable image - word image version
For travel on or after 1/1/14

Mileage form
Minutes of hearing fillable image WCAB 20
Minutes of hearing - addendum fillable image WCAB 20.2
Notice of dismissal of attorney fillable image DWC WCAB 37
Notice of employee death acrobat image DIA 510
Objection to treating physician's recommendation for spinal surgery fillable image DWC form 233
Petition for appointment of guardian ad litem and trustee fillable image DWC WCAB 8
Petition for change of primary treating physician fillable image DWC 280
Petition for commutation of future payments fillable image DWC WCAB 49
Petition for reconsideration fillable image DWC WCAB 45
Petition to reopen
Note: A declaration of readiness to proceed must also be filed with this form.
See I&A guide 11 for more detailed instructions.fillable image
DWC WCAB 42
Pre-trial conference statement lien issues addendum fillable image WCAB 24.1
Pre-trial conference statement WCAB 24
Pre-trial conference statement 9/2010 fillable image DWC CA 10253.1
Special notice of lawsuit fillable image
Substitution of attorneys fillable image DWC WCAB 36 Sample
Workers' compensation claim form - effective 10/8/2010 fillable image DWC 1

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Access to public records Number
Request for Public Records fillable image
Request for authorization number form fillable image DWC AD 3

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Utilization review forms Number
Utilization review complaint form fillable image - word image version
Note: If you want to save this form to your computer and email it to the DWC Medical Unit, you MUST use the Word version. The PDF version cannot be saved to your computer once filled
DWC UR 1

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Fraud reporting forms Number
Report of suspected medical care provider fraud fillable image DWC SMBFR 1115

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Independent Bill Review - IBR forms Number
Request for Independent Bill Review acrobat image DWC Form IBR-1
Provider's Request for Second Bill Review DWC Form SBR-1

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Independent Medical Review - IMR forms Number
Application for Independent Medical Review fillable image DWC IMR
Request for Authorization for Medical Treatment fillable image 9785.5

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Judicial ethics forms                                                            
Complaint form and information fillable image

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Lien filing and activation fees Number
Lien filing and activation fees fillable image Form A

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Pre-designation of personal physician / Change of physician forms Number

NOTE: The regulations that these forms implement have an effective date of July 1. The Division is posting them in advance of their July 1 effective date to allow employers and claims administrators time to reproduce and distribute them before that date.

Notice of personal chiropractor or personal acupuncturist fillable image - En español acrobat image

DWC 9783.1
Notice of pre-designation of personal physician fillable image - En español acrobat image DWC 9783

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Primary treating physician forms Number
Primary treating physician's permanent and stationary report fillable image
2005 permanent disability rating schedule
DWC
PR-4
Primary treating physician's permanent and stationary report fillable image
1997 permanent disability rating schedule
DWC
PR-3
Primary treating physician's progress report fillable image DWC
PR-2

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Qualified medical evaluator - QME and agreed medical evaluator - AME forms Number
Additional panel request fillable image
QME 31.7
AME or QME declaration of service of medical - legal report fillable image QME 122
Application for accreditation or re-accreditation as education provider fillable image - Instructions acrobat image QME 118
Application for appointment as qualified medical evaluator fillable image QME 100
Course Evaluation for Administrative Director QME 117
Declaration regarding protection of mental health record fillable image QME 121
Faculty disclosure of commercial interest fillable image QME 119
QME appointment notification form fillable image QME 110
QME disclosure of specified financial interests fillable image QME 124
QME notice of unavailability fillable image QME 109
QME or AME conflict of interest disclosure form and objection or waiver fillable image Instructions acrobat image QME 123
QME/AME report time frame extension request fillable image QME 112
Qualified medical evaluator's findings summary form - unrepresented cases only fillable image QME 111
Reappointment application as qualified medical evaluator fillable image QME 104
Registration for QME competency examination fillable image QME 102
Replacement panel request fillable image QME 31.5
Represented additional panel - Proof of service  
Represented replacement panel - Proof of service  
Request for Factual Correction of a Unrepresented Panel QME Report QME 37
Request For QME panel under Labor Code Section 4062.1 - Unrepresented fillable image
QME 105
Request For QME panel under Labor Code Section 4062.1 - Spanish - Unrepresented fillable image
QME 105
Request For QME panel under Labor Code Section 4062.2 - Represented fillable image
QME 106
Unrepresented additional panel - Proof of service  
Unrepresented replacement panel - Proof of service  
Voluntary directive for alternate service of medical-legal evaluation report on disputed injury to psyche fillable image QME 120

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Supplemental Job Displacement Benefit Number
Notice of Offer of Regular Work fillable image
Injuries occurring between 1/1/05 - 12/31/12, Inclusive
DWC - AD 10118
Supplemental Job Displacement Non-Transferable Voucher fillable image
Injuries occurring on or after 1/1/13
DWC - AD 10133.32
Description Of Employee's Job Duties fillable image DWC - AD 10133.33
Notice of Offer Of Regular Modified Or Alternative Work fillable image
Injuries occurring on or after 1/1/13
DWC - AD 10133.35
Physician's Return-to-Work & Voucher Report fillable image DWC - AD 10133.36
Notice Of Offer Of Modified Or Alternative Work fillable image
Injuries occurring between 1/1/04 - 12/31/12
DWC - AD 10133.53
Request for Dispute Resolution Before Administrative Director fillable image DWC - AD 10133.55
Supplemental Job Displacement Nontransferable Training Voucher fillable image
Injuries occurring between 1/1/04 - 12/31/12
DWC - AD 10133.57

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Disability evaluation forms Number
Apportionment fillable image DEU 105
Commutation request Excel image
Notice of options following disability rating - En español acrobat image DEU 110

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Medical provider network - MPN forms Number
Cover Page for Medical Provider Network Application or Plan for Reapproval fillable image DWC 9767.4
Notice of medical provider network plan modification Labor Code 9767.8 fillable image DWC 9767.8
Medical Provider Network Complaint fillable image DWC 9767.16.5
Petition for Suspension or Revocation of a Medical Provider Network , Part A fillable image
MPN Response to Petition for Suspension or Revocation of a Medical Provider Network, Part B fillable image
DWC 9767.17.5
DWC 9767.17.5
Independent medical review application fillable image - En español fillable image
For injured workers who need to get an independent medical review
DWC 9768.10
Physician contract application fillable image
for doctors who want to become independent medical reviewers
DWC 9768.5

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Audit forms Number
Audit referral form fillable image DWC-AU-906
Annual report of adjusting locations for claims administrators whose ARI requirements have been waived fillable image DWC-857
Audit report of inventory 2012 fillable image DWC-851
How to file a complaint with the Audit Unit acrobat image DWC-AU -905

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Carve out agreement forms Number
Petition for permission to negotiate a section 3201.7 labor-management agreement fillable image DWC RGS-1

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Complaint forms Number
How to file a complaint with the Audit Unit acrobat image DWC-AU -905
Qualified medical evaluator - QME complaint form fillable image
Utilization review complaint form fillable image DWC -UR 1

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September 2014