Texas Department of Insurance

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Workers' Compensation Health Care Networks Forms

This is one of several pages linking to a central repository of forms used by TDI customers. Use the search or Forms by Type links on the Forms Home Page or scan through our form listings.

Life, Accident and Health - Workers' Compensation Health Care Networks Forms
TDI Form NumberDescriptionFile FormatLanguage
FIN306 Officers and Directors Page
Complete Listing of all Current Officers and Directors - compliance with statutes		 PDFEnglish
Life, Accident and Health - Workers' Compensation Health Care Networks Forms
TDI Form NumberDescriptionFile FormatLanguage
LHL361 Workers Compensation Utilization Review Adverse Determination Summary
Checklist 		EXCEL
LHL390 WC Network Biographical Affidavit Form
Workers' Compensation Health Care Network Biographical Affidavit		 WORD
LHL390 WC Network Biographical Affidavit Form
Workers' Compensation Health Care Network Biographical Affidavit		 PDFEnglish
LHL392 WC Network Application Certification Requirements Checklist
Workers' Compensation Health Care Network Application Certification Requirements Checklist		 PDFEnglish
LHL399 WC Network Access Plan Checklist
List of requirements for a WC Network Access Plan		 WORD
LHL 416 WC Network - Network Adequacy Checklist
 PDFEnglish
LHL 417 WCNetwork Complaints Policies & Procedures
 PDFEnglish
LHL 418 WC Network Operations Checklist
 PDFEnglish
LHL 419 WC Network Credentialing Policy & Procedure Checklist
 PDFEnglish
LHL 420 WC Network Quality Improvement Checklist
 PDFEnglish
LHL423 Insurance Carrier Contract Checklist
Insurance Carrier Contract Checklist		 PDFEnglish
LHL424 Provider Contract Checklist
Provider Contract Checklist		 PDFEnglish
LHL425 WC Network Application Form
Workers' Compensation Health Care Network Application		 PDFEnglish
LHL425 WC Network Application Form
Workers' Compensation Health Care Network Application		 WORD
LHL426 WCNet configuration modification checklist
Workers' Compensation Network configuration modification checklist		 PDFEnglish
LHL427 Management Services Checklist
Management Services Checklist		 PDFEnglish
Additional Workers' Compensation Health Care Networks Forms
TDI Form Number Description File Format
  Workers' Compensation Complaint Form HTML
  QI Plan Report
Sample Quality Improvement Report Formats 		WORD
  Employee Acknowledgment Form Samples HTML
  Sample Contingency Plan for Delegated Functions form WORD

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