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Workers' Compensation Medical Forms

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. 11/17
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. 11/17
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
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

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