PERVIOUS FORMS

Access to Public Records
Request for Public Records  
Request for authorization number form DWC form AD 3
Audit  
Audit referral form DWC-AU-906
How to file a complaint with the Audit Unit

 

 DWC-AU -905

 
Carve out Agreement  
Petition for permission to negotiate a section

 3201.7 labor-management agreement

 DWC form RGS-1

 
Claim and Court Forms  
Medical mileage expense form in English/Spanish - for travel between 7/1/06 and 1/1/07  
Pre-trial conference statement  
Petition to reopen DWC WCAB form 42
Petition for commutation of future payments DWC WCAB form 49
Stipulation and award and/or order DWC WCAB form 5
Petition for reconsideration DWC WCAB form 45
Petition for change of primary treating physician DWC form 280
Medical mileage expense form in English/Spanish - for travel on or after 1/1/07  
Notice of dismissal of attorney  DWC WCAB form 37
Notice of employee death  DIA 510
Application for benefits for serious and willful misconduct of employer  
Notice and request for allowance of lien DWC WCAB form 6
Minutes of hearing/order/order and decision on request for continuance/order taking off calendar/notice of hearing  
Petition for appointment of guardian ad litem and trustee DWC WCAB form 8
Medical mileage expense form in English/Spanish - for travel on or after 1/1/08  
Medical mileage expense form in English/Spanish - for travel on or after 7/1/08 I&A mileage form
Information guidelines for submission of settlement documents  
Declaration of readiness to proceed - expedited hearing (trial)      DWC WCAB form 4
Declaration of readiness to proceed DWC WCAB form 9
Objection to treating physician's recommendation for spinal surgery DWC form 233
Application for discrimination benefits pursuant to Labor Code section 132(A)  
Application for adjudication of claim DWC WCAB form 1
Appeal from determination and order of the Rehabilitation Unit  
Request for consultative rating  
Request for reconsideration of summary rating by the administrative director DEU Form 103
Workers' compensation claim form DWC 1
Stipulations with request for award DWC WCAB form 3
Compromise and release

 

 DWC WCAB form 15

 
Primary treating physician  
Primary treating physician's progress report  DWC form PR-2
Primary treating physician's permanent and stationary report DWC form PR-4 (2005 Rating Sched
Primary treating physician's permanent and stationary report

 

 DWC form PR-3 (1997 Rating Sched

 
Utilization Review Forms  
Utilization review complaint form

 

 DWC UR form 1

 
Vocational rehabilitation benefit  
Settlement of prospective vocational rehabilitation services RU 122
Declination for dates of injury pre 1/1/90 RB 107
Treating physician report of disability RU 90
Request for dispute resolution and instructions RU 103
Request for conclusion RB 105
Rehabilitation plan RU 102
Progress report RU 121
Notice of termination RU 105
Notice of offer of modified or alternate work RU 94
Description of job duties RU 91
Declination for dates of injury post 1/1/94 RU 107A
Declination for dates of injury 1/1/90 - 12/31/93 RU 107
Evaluation summary RU 120
 

 

 

 

 

 

 

 

 

 

 

 

 

 

  
Administrative
Notice of employee death DIA 510
Request for accommodations by persons with disability DWC form 5
Physician's guide order form  
Arbitrator application  
Notice to employees poster (English and Spanish)  
Employer's report of occupational injury or illness DLSR 5020
EDEX subscriber application  
EDEX client list  
Doctor's first report of occupational injury or illness  DLSR 5021
EDEX client acknowledgment of legal constraints on access/use to information  
Official medical fee schedule order form

 

  

 
Disability evaluation  
Request for informal rating (by insurance carrier or self-insurer) DEU 201
Request for summary rating determination (of primary treating physician's report) DEU 102
Notice of options following disability rating DEU 110
Apportionment DEU 105
Request for summary rating determination (of AME's or QME 's report) DEU 101
Request for reconsideration of summary rating by the administrative director  DEU 103
Request for consultative rating  
Employee's request for informal permanent disability rating DEU 200
Employee's permanent disability questionnaire

 

 DEU 100

 
Fraud Reporting  
Report of suspected medical care provider fraud

 

 DWC form SMBFR 1115

 
Judicial Ethics  
Complaint form and information

 

  

 
MPN  
Ejemplo de la notificación inicial escrita del empleado sobre la Red de proveedores médicos  
Notice of medical provider network plan modification ?9767.8 DWC form 9767.8
Sample initial written employee notification re: Medical provider network  
Physician contract app. for doctors who want to become independent medical reviewer DWC form 9768.5
Independent medical review app. (for injured workers who need to get an independent review)  
Cover page for medical provider network application

 

 DWC form 9767.4

 
Pre-designation personal physician/ Change of physician  
Notice of personal chiropractor or personal acupuncturist DWC form 9783.1
Notice of pre-designation of personal physician DWC form 9783
Noticia de quiropráctico personal o acupuntor personal  
Designación previa de médico particular

 

  
QME and AME  
Qualified medical evaluator appointment notification form IMC form 110
Application for accreditation or re-accreditation as education provider IMC form 118
Qualified or agreed medical evaluator's findings summary IMC form 111
Qualified medical evaluator letter IMC form 108
Qualified medical evaluator exam packet - Oct. 25, 2008  
Reappointment application as qualified medical evaluator IMC form 104
QME/AME time frame extension request IMC form 112
Notice of qualified medical evaluator unavailability IMC form 109
Request for qualified medical evaluator IMC form 106
How to request a qualified medical evaluator IMC form 105
Qualified medical evaluator fees IMC form 103