• Increase Text Icon
  • Decrease Text Icon
  • Email Icon
  • Print this page
You are here: Home . forms . form20medical

Workers' Compensation Medical Forms

Division of Workers Compensation Main Forms page

Workers' Compensation Medical Forms
TDI Form Number Description File FormatLanguage
DWC044
Election to Engage in Arbitration
Rev. 06/12
PDF English
DWC044S
Elección para Participar en un Arbitraje
Rev. 06/12
PDF Spanish
DWC045M
Request to Schedule, Reschedule, or Cancel a Benefit Review Conference to Appeal a Medical Fee Dispute Decision (BRC-MFD)
Rev. 02/17
PDF English
DWC045MS
Solicitud para Programar, Reprogramar, o Cancelar una Conferencia para Revisión de Beneficios para Apelar la Decisión de una Disputa por Honorarios Médicos
Rev. 02/17
PDF Spanish
DWC049
Request to Schedule a Medical Contested Case Hearing (MCCH)
Rev. 02/17
PDF English
DWC049S
Solicitud para Programar una Audiencia para Disputar Beneficios Médicos (Medical Contested Case Hearing –MCCH, por su nombre y siglas en inglés)
Rev. 02/17
PDF Spanish
DWC060
Medical Fee Dispute Resolution Request
Rev. 06/12
PDF English
DWC060S
Solicitud para Resolución de Disputas por Honorarios Médicos
Rev. 06/12
PDF Spanish
DWC064
Medical Interlocutory Order Request - Continued Use of a Drug Previously Prescribed and Dispensed and Excluded from TDI-DWC’s Closed Formulary
Rev. 8/11
PDF English
DWC065
Application for Inclusion on Registry of Private Providers of Vocational Rehabilitation Services
Rev. 1/11
PDF English
DWC066
Statement of Pharmacy Services
Rev. 12/11
PDF English
DWC067
Designated Doctor Certification Application
Rev. 8/16 - for use on or after 9/1/16
PDF English
DWC068
Designated Doctor Examination Data Report
Rev. 2/17
PDF English
DWC069
Report of Medical Evaluation
Rev. 1/15 (for use on or after 1/1/15)
PDF English
DWC070
Instructions For Completing The ADA J515 Dental Claim Form For Texas Workers' Compensation Claims
Rev. 10/05
PDF English
DWC072
Medical Quality Review Panel Application
Rev. 01/13
PDF English
DWC073
Work Status Report
Rev. 02/11
PDF English
DWC074
Description of Injured Employee’s Employment
Rev. 9/09
PDF English
DWC154
Workers' Compensation Complaint Form
Rev. 03/16
PDF English
LHL009
Request for Review by an IRO
Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity
PDF English
LHL009 Spanish
Request for Review by an IRO
[ En Español ] - Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity
PDF Spanish

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.


For more information, contact:

Contact Information and Other Helpful Links