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Forms

Fillable form instructions = Fillable Adobe Acrobat form - en español = Adobe Acrobat for = Word form

Forms are grouped by relevant subject, then in alphabetical order. Use the arrows to change to reverse alphabetical order or search by form number. The ten most-downloaded forms also appear in the “Frequently used forms” section.

Frequently used forms

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Audit forms

Form

Number
   
Audit referral form DWC-AU-906
Annual report of adjusting locations for claims administrators whose ARI requirements have been waived DWC-857
Audit report of inventory  DWC-851
Complaint form: Audit Unit DWC-AU -905

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Complaint forms

Form

Number
   

Complaint form: Utilization review   -  word 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
Report of suspected medical care provider fraud  DWC SMBFR 1115
Complaint form: Workers' Compensation Judge  
Complaint form: Audit Unit DWC-AU -905
Complaint form: Qualified medical evaluator (QME)  
Complaint form: Medical Provider Network DWC 9767.16.5

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Court forms

Form Number
   
Compromise and release - dependency claim DWC-CA 10214-d
Compromise and release - third party  DWC-CA 10214-e
Declaration of readiness to proceed - expedited trial DWC-CA 10208.3
Declaration of readiness to proceed DWC-CA 10250.1
Document cover sheet 
DWC-CA 10232.1
Body part codes list
 
Proof of service   
Document separator sheet 
* click paperclip for document titles and document types
DWC-CA 10232.2
Stipulations with request for award - death case  DWC-CA 10214-b
Stipulations with request for award  
* For injury on or after 1-1-2013
DWC-CA 10214-a
Stipulations with request for award 
* For injury prior to 1-1-2013
DWC-CA 10214-a
Supplement to minutes of hearing WCAB 20.1
Application for adjudication of claim 
* How to submit an amended application for adjudication of claim
WCAB 1
Answer to application for adjudication of claim WCAB 10
Notice and request for allowance of lien WCAB 6
Petition to terminate liability for temporary disability indemnity WCAB 46
Arbitrator submittal   
Request for accommodations by persons with disability  DWC 5
Addendum to application for adjudication of claim to identify legal entity employing injured worker WCAB 2
Application for adjudication of claim - Death case DIA 2
Application for benefits for serious and willful misconduct of employer   
Application for discrimination benefits pursuant to Labor Code section 132 - A  
Attorney fee disclosure statement DWC 3
Declaration pursuant to Labor Code section 4906 - g  
Minutes of hearing WCAB 20
Minutes of hearing - addendum  WCAB 20.2
Notice of dismissal of attorney DWC WCAB 37
Notice of employee death  DIA 510
Petition for appointment of guardian ad litem and trustee DWC WCAB 8
Petition for change of primary treating physician DWC 280
Petition for commutation of future payments  DWC WCAB 49
Petition for reconsideration DWC WCAB 45
Petition to reopen DWC WCAB 42
Pre-trial conference statement WCAB 24
Pre-trial conference statement lien issues addendum  WCAB 24.1
Special notice of lawsuit  
Substitution of attorneys DWC WCAB 36
Verification  
Compromise and release DWC-CA 10214-c
Information guidelines for submission of settlement documents  

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Disability Evaluation forms

Form

Number
   
Employee's permanent disability questionnaire DWC-AD 100
Request for consultative rating DWC-AD 104
Request for reconsideration of summary rating by the administrative director DWC-AD 103
Request for summary rating determination of Qualified Medical Evaluator's (QME) Report                DWC-AD 101
Request for summary rating determination - primary treating physician report  DWC-AD 102
Apportionment request  DEU 105
Commutation request  

Notice of options following disability rating

DEU 110

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Employer forms

Form

Number
   
Workers' compensation claim form DWC 1
Employer's report of occupational injury or illness DLSR 5020
Petition for permission to negotiate a section 3201.7 labor-management agreement DWC RGS-1

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Independent Bill Review forms

Form

Number
   
Provider's request for second bill review DWC Form SBR-1
Request for independent bill review DWC Form IBR-1

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Independent Medical Review forms

Form

Number
   
Application for Independent Medical Review DWC IMR
Petition appealing administrative director’s independent medical review determination

 
Request for authorization for medical treatment  9785.5

Independent medical review application

* For injured workers who need to get an independent medical review

DWC 9768.10
Physician contract application
* For doctors who want to become independent medical reviewers
DWC 9768.5

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Lien forms

Form

Number
   
Lien filing fees refund request Form A
Lien conference disposition WCAB 27

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Medical forms

Form

Number
   
Doctor's first report of occupational injury or illness 5021
Official medical fee schedule order form  
Physician's guide order form  
Primary treating physician's permanent and stationary report 
* 2005 permanent disability rating schedule
DWC PR-4

Primary treating physician's permanent and stationary report 
* 1997 permanent disability rating schedule

DWC PR-3
Primary treating physician's progress report DWC PR-2
Medical mileage expense form English/Spanish  - word version 
* For travel on or after 1/1/16
Mileage form
Objection to treating physician's recommendation for spinal surgery DWC form 233

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Medical Provider Network forms

Form

Number
   
Cover page for medical provider network application or plan for reapproval DWC 9767.4
Notice of medical provider network plan modification  DWC 9767.8
Complaint form: Medical Provider Network DWC 9767.16.5
Petition for suspension or revocation of a medical provider network - Part A 
DWC 9767.17.5
MPN response to petition for suspension or revocation of a medical provider network - Part B DWC 9767.17.5

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Pre-designation forms

Form

Number
   
Notice of personal chiropractor or personal acupuncturist
DWC 9783.1
Notice of pre-designation of personal physician 
DWC 9783
Noticia de quiropráctico personal o acupuntor personal DWC 9783.1
Designación previa de médico personal DWC 9783

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Public records forms

Form

Number
   
 Request for public records     
Request for authorization number form                     DWC AD 3

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QME/AME forms

Form

Number
   
Additional QME panel request QME 31.7
AME or QME declaration of service of medical - legal report QME 122
Application for accreditation or re-accreditation as education provider QME 118
Application for appointment as qualified medical evaluator QME 100
Course Evaluation for Administrative Director (QME) QME 117
Declaration regarding protection of mental health record QME 121
Faculty disclosure of commercial interest QME 119
QME appointment notification form QME 110
QME disclosure of specified financial interests QME 124
QME notice of unavailability  QME 109
QME or AME conflict of interest disclosure form and objection or waiver QME 123
QME/AME report time frame extension request  QME 112
Qualified medical evaluator's findings summary form - unrepresented cases only QME 111
Reappointment application as qualified medical evaluator QME 104
Registration for QME competency examination QME 102
Replacement panel request QME 31.5
Proof of service: Represented additional panel  
Proof of service: Represented replacement panel  
Request for Factual Correction of a Unrepresented Panel QME Report QME 37
Request For QME panel under Labor Code Section 4062.1 - Unrepresented QME 105
Solicitud De Panel De Evalua dor Medicó Calificado- Empleado sin representación legal

QME 105
Request For QME panel under Labor Code Section 4062.2 
* For injuries occurring prior to 1/1/05 Represented
* Note: For injuries on or after 1/1/05, online only as of Oct. 1, 2015. No paper submissions postmarked after Sept. 3, 2015.
QME 106
Proof of service: Unrepresented additional QME panel  
Proof of service: Unrepresented replacement panel  
Voluntary directive for alternate service of medical-legal evaluation report on disputed injury to psyche QME 120
Complaint form: Qualified medical evaluator (QME)  

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SIBTF/UEBTF forms

Form

Number
   
Application for discretionary payments from the uninsured employers' fund             DWC-UEF 50
Application for subsequent injuries fund benefits  

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Supplemental Job Displacement Benefits forms

Form

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

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Comments? Questions? Suggestions? Email dwc@dir.ca.gov

 

September 2016