Today is
Friday, April 04, 2025 -
WCC PDF Forms
| Form Name | Form Number |
|---|---|
| Finding and Order (Replacement QME Unrepresented) | |
| Finding and Order RE: Second QME Panel (Unrepresented Case) | |
| Finding and Order RE:Second QME Panel (represented case) | |
| General Information and Instructions, Effective for Dates of Service on or after January 1, 2004 | 9789.11(a)(1) |
| General Information and Instructions, Effective for Dates of Service on or after July 1, 2004 | 9789.11(a)(1) |
| Getting Appropriate Medical Care for Your Injury (October 2006) | |
| Glossary of workers' compensation terms for injured workers (07-2005) | Fact Sheet B |
| Glossary of workers' compensation terms for injured workers - Spanish (09-2005) | Fact Sheet B |
| HCO Enrollment Form | WC-HCO1 |
| How to file a complaint with the Audit Unit (06-2006) | DWC-AU-905 |
| How to Request A QME-If you do not have a lawyer | IMC 105 |
| Independent medical review application | |
| Medical Mileage Expense Form (01-2009) | I&A mileage form |
| Medical Mileage Expense Form (06-2011) | |
| Medical Mileage Expense Form - English and Spanish (01-2008) | |
| Medical mileage expense form in English/Spanish - for travel between 07-01-2006 and 01-01-2007 | IA mileage form |
| Medical mileage expense form in English/Spanish - for travel on or after 01-01-2007 | IA mileage form |
| NOTICE OF OFFER OF REGULAR WORK (for injuries aft 1/1/05) | DWC-AD 10003 |
| NOTICE OF PERSONAL CHIROPRACTOR OR PERSONAL ACUPUNCTURIST | DWC 9783.1 |
| Notice of pre-designation of personal physician - Spanish (03-2007) | DWC 9783 |
| Notice of QME Unavailability | IMC-12210 |
| Official Medical Fee Schedule order form | omfsord |
| Order for Panel QME 8 CCR Section 32.1(C)(Represented) | |
| Petition for Resolution of Reimbursment Dispute | AHCA Form 3160-0023 |
| Physician Contract Application (Independant Medical Reviewer) 05-2007 | DWC 9768.5 |
| Pre-Trial Conference Statement (Liens) | Pre-Trial |
| Predesignation of Personal Physician (03-01-2007) | DWC 9783 |
| Primary treating physician's permanent and stationary report - 1997 permanent disability rating schedule (06-2005) | DWC PR-3 |
| Primary treating physician's permanent and stationary report - 2005 permanent disability rating schedule (06-2005) | DWC PR-4 |
| Primary treating physician's progress report (6-2005) | DWC PR-2 |
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