WCC PDF Forms

Form Name	Form Number
9792.1 Appendix B (DRG Weights and Revised DRG Weights)	Appendix B
A Guidebook for Injured Workers, 3rd Ed. (Nov. 2006)
A Guidebook for Injured Workers, 3rd Ed. - Spanish (Nov. 2006)
AME or QME declaration of service of medical - legal report	QME Form 122
Answers to your questions about permanent disability benefits (12-2005)	Fact Sheet D
Answers to your questions about permanent disability benefits - Spanish (01-2006)	Fact Sheet D
Answers to your questions about qualified medical evaluators and agreed medical evaluators (12-2005)	Fact Sheet E
Answers to your questions about qualified medical evaluators and agreed medical evaluators - Spanish (04-2007)	Fact Sheet E
Answers to your questions about temporary disability benefits (12-2005)	Fact Sheet C
Answers to your questions about temporary disability benefits - Spanish (01-2006)	Fact Sheet C
Answers to your questions about utilization review (01-2006)	Fact Sheet A
Answers to your questions about utilization review - Spanish (08-2006)	Fact Sheet A
Appendix A: Payment Of Inpatient Services Of Health Facilities	Appendix A
Appendix C: Ratios Applied To Revise Certain DRG Weights In California	Appendix C
Application for accreditation or re-accreditation as education provider	QME Form 118
Application for Appointment as Qualified Medical Evaluator	QME Form 100
Application for discrimination benefits pursuant to Labor Code section 132(A)
Application for Spinal Surgery 2nd Opinion Physician List (05/2007)	Form 232
Apportionment (01-01-2005)	DEU 105
Arbitrator Submittal Form	Form 10297
Audit Referral Form (06-2006)	DWC-AU-906
Billing and Statement of Charges for Medical-Legal Reports	IMC-76
Choosing Medical Care For Work Related Injuries and Illnesses	DW 1194
Cover Page for Medical Provider Network Application	DWC 97674
Declaration Regarding Protection of Mental Health Record	QME Form 121
Doctor's First Report Of Occupational Injury Or Illness	5021
Election for High Cost Outlier	DWC 15
Employee's Request For Informal Permanent Disability Rating	DEU 200
Faculty Disclosure of Commercial Interest	QME Form 119
Finding and Order (Replacement QME Represented)