This information is provided free of charge by the Department of Industrial Relations from its web site at These regulations are for the convenience of the user and no representation or warranty is made that the information is current or accurate. See full disclaimer at

Chapter 4.5. Division of Workers' Compensation

Subchapter 1. Administrative Director--Administrative Rules

Article 3.6. Independent Medical Review

New query

§9768.5. Physician Contract Application Form

Physician application contract DWC form 9768.5 (pdf)

Note to physicians: please use three letter specialty code when completing block 3 of application form)
MAI Allergy and Immunology
MAA Anesthesiology
MRS Colon & Rectal Surgery
MDE Dermatology
MEM Emergency Medicine
MFP Family Practice
MPM General Preventive Medicine
MOSU Hand - Orthopaedic Surgery, Plastic Surgery, General Surgery
MMM Internal Medicine
MMV Internal Medicine - Cardiovascular Disease
MME Internal Medicine - Endocrinology Diabetes and Metabolism
MMG Internal Medicine - Gastroenterology
MMH Internal Medicine - Hematology
MMI Internal Medicine - Infectious Disease
MMO Internal Medicine - Medical Oncology
MMN Internal Medicine - Nephrology
MMP Internal Medicine - Pulmonary Disease
MMR Internal Medicine - Rheumatology
MPN Neurology
MNS Neurological Surgery
MNM Nuclear Medicine
MOG Obstetrics and Gynecology
MPO Occupational Medicine
MOP Opthalmology
MOSG Orthopaedic Surgery (General)
MOSS Orthopaedic - Shoulder
MOSK Orthopaedic - Knee
MOSB Orthopaedic - Spine
MOSF Orthopaedic - Foot and ankle
MTO Otolaryngology
MAP Pain Management - Psychiatry and Neurology, Physical Medicine and Rehabilitation, Anesthesiology
MHA Pathology
MEP Pediatrics
MPR Physical Medicine & Rehabilitation
MPS Plastic Surgery
MPD Psychiatry
MSY Surgery
MSG Surgery - General Vascular
MTS Thoracic Surgery
MTO Toxicology - Preventive Medicine, Pediatrics, Emergency
MUU Urology
MRD Radiology
POD Podiatry
DWC Form 9768.5 11/2006

Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Section 4616.4, Labor Code.Authority cited: Sections 133 and 4616, Labor Code. Reference: Section 4616.4, Labor Code.


1. New section filed 12-31-2004 as an emergency; operative 1-1-2005 (Register 2004, No. 53). A Certificate of Compliance must be transmitted to OAL by 5-2-2005 or emergency language will be repealed by operation of law on the following day.

2. Certificate of Compliance as to 12-31-2004 order, including amendment of section, transmitted to OAL 4-29-2005 and filed 6-10-2005 (Register 2005, No. 23).

3. Change without regulatory effect amending form filed 10-18-2006 pursuant to section 100, title 1, California Code of Regulations (Register 2006, No.42).

Go Back Go Back to Subchapter 1 Table of Contents