Workers' Compensation Medical 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.
Division of Workers Compensation Main Forms page
En Español
English
Health Care Provider/Medical Forms
| 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
Health Care Provider/Medical Forms
| DWC044 |
Election to Engage in Arbitration
(Rev. 06/12, for disputes filed on or after June 1, 2012) |
PDF |
| DWC045M |
Request to Schedule, Reschedule, or Cancel a Benefit Review Conference to Appeal a Medical Fee Dispute Decision (BRC-MFD)
(Rev. 06/12, for disputes filed on or after June 1, 2012) |
PDF |
| DWC049 |
Request to Schedule a Medical Contested Case Hearing (MCCH)
(Rev. 06/12, for disputes filed on or after June 1, 2012) |
PDF |
| DWC060 |
Medical Fee Dispute Resolution Request
(Rev. 06/12, for disputes filed on or after June 1, 2012) |
PDF |
| DWC060 |
Medical Fee Dispute Resolution Request/Response
(Rev. 02/07, for disputes filed on or before May 31, 2012) |
PDF |
| DWC060 |
Medical Fee Dispute Resolution Request/Response
(Rev. 02/07, for disputes filed on or before May 31, 2012) |
WORD |
| DWC062 |
Explanation of Benefits
(Rev. 07/07) |
PDF |
| 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 |
| DWC065 |
Application for Inclusion on Registry of Private Providers of Vocational Rehabilitation Services
(Rev. 1/11) |
WORD |
| DWC065 |
Application for Inclusion on Registry of Private Providers of Vocational Rehabilitation Services
(Rev. 1/11) |
PDF |
| DWC066 |
Statement of Pharmacy Services
(Rev. 12/11) |
PDF |
| DWC069 |
Report of Medical Evaluation
(Rev. 6/11) Sample Notice for Health Care Provider (PDF, Word) |
PDF |
| DWC070 |
Instructions For Completing The ADA J515 Dental Claim Form For Texas Workers' Compensation Claims
(Rev. 10/05) |
PDF |
| DWC073 |
Work Status Report
(Rev. 02/11) |
PDF |
| DWC074 |
Description of Injured Employee’s Employment
(Rev. 9/09) |
PDF |
En Español
Health Care Provider/Medical Forms
|
| LHL009 |
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 |
En Español
Health Care Provider/Medical Forms
|
| DWC044S |
Elección para Participar en un Arbitraje
(Rev. 06/12, para disputas que son presentadas en o después del 1º de junio de 2012) |
PDF |
| DWC045MS |
Solicitud para Programar, Reprogramar, o Cancelar una Conferencia para Revisión de Beneficios para Apelar la Decisión de una Disputa por Honorarios Médicos (Benefit Review Conference to Appeal a Medical Fee Dispute Decision –BRC-MFD, por su nombre y siglas en inglés)
(Rev. 06/12, para disputas que son presentadas en o después del 1º de junio de 2012) |
PDF |
| DWC049S |
Solicitud para Programar una Audiencia para Disputar Beneficios Médicos (Medical Contested Case Hearing –MCCH, por su nombre y siglas en ingles)
(Rev. 06/12, para disputas que son presentadas en o después del 1º de junio de 2012) |
PDF |
| DWC060s |
Solicitud para Resolución de Disputas por Honorarios Médicos/Respuesta
(Rev. 2/07, for disputes filed on or before May 31, 2012) |
PDF |
| DWC060S |
Solicitud para Resolución de Disputas por Honorarios Médicos
(Rev. 06/12, para disputas que son presentadas en o después del 1º de junio de 2012) |
PDF |
| DWC060S |
Solicitud para Resolución de Disputas por Honorarios Médicos/Respuesta
(Rev. 2/07, for disputes filed on or before May 31, 2012) |
WORD |
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