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.
Instructions for completing the standard medical billing forms and the explanation of benefits (DWC-062) may be found in Chapter 2 of the "Texas Clean Claim and eBill Workers' Compensation Companion Guide" [ http://www.tdi.state.tx.us/wc/ebill/index.xml#ebcg ].
Numerical Listing of Division of Workers' Compensation Forms and Checklists
|
| DWC001 |
Employer's First Report of Injury or Illness
(Rev. 10/05) This form is submitted to by carrier to DWC (with cover sheet and instructions) |
PDF | English |
| DWC001S |
Employer's First Report of Injury or Illness (for state employees)
(Rev. 10/05) |
PDF | English |
| DWC002 |
Employer's Report for Reimbursement of Voluntary Payment
(Rev. 10/05) |
PDF | English |
| DWC003 |
Employer's Wage Statement
(Rev. 10/05) |
PDF | English |
| DWC003ME |
Employee's Multiple Employment Wage Statement
(Rev. 10/05) |
PDF | English |
| DWC003MES |
Declaración de Salario de Múltiples Trabajos del Empleado
(Rev. 10/05) |
PDF | Spanish |
| DWC003S |
Declaración de Salario del Empleador
(Rev. 10/05) |
PDF | Spanish |
| DWC003SD |
Employer's Wage Statement for School Districts
(Rev. 10/05) |
PDF | English |
| DWC003SDS |
Declaración de Salario Para Escuelas de Distrito
(Rev. 10/05) |
PDF | Spanish |
| DWC004 |
Employer's Contest of Compensability
(Rev. 11/08) |
PDF | English |
| DWC005 |
Employer Notice of No Coverage or Termination of Coverage
(Rev. 11/10) |
PDF | English |
| DWC005s |
Notificación del Empleador por No Cobertura o Anulación de la Cobertura
(Rev. 11/10) |
PDF | Spanish |
| DWC006 |
Supplemental Report of Injury
(Rev. 10/05) |
PDF | English |
| DWC007 |
Non-Covered Employer's Report of Occupational Injury or Illness
(Rev. 10/05) |
PDF | English |
| DWC007SUP |
Supplement DWC 7, Non-Covered Employer's Report of Occupational Injury or Illness
(Rev. 10/05) |
PDF | English |
| DWC008 |
Return-to-Work Reimbursement Program for Employers
(Rev. 04/10) |
WORD | English |
| DWC008 |
Return-to-Work Reimbursement Program for Employers
(Rev. 04/10) |
PDF | English |
| DWC020 |
Insurance Carrier's Notice of Coverage/Cancellation/Non-Renewal of Coverage
(Rev. 10/05) |
PDF | English |
| DWC020A |
Correction/Revision/Endorsement to Existing Policy
(Rev. 10/05) |
PDF | English |
| DWC020SI |
Self-Insured Governmental Entity Proof of Coverage
(Rev. 10/06) |
PDF | English |
| DWC022 |
Required Medical Examination (RME) - Request for Agreement / Request for Order
Rev. 7/11 |
PDF | English |
| DWC022S |
Examen Médico Requerido (Required Medical Examination –RME, por su nombre y siglas en inglés) – Solicitud para un Acuerdo / Solicitud para una Orden
Rev. 7/11 |
PDF | Spanish |
| DWC024 |
Benefit Dispute Agreement
(Rev. 10/05) |
PDF | English |
| DWC024s |
Acuerdo para Disputa de Beneficios
(Rev. 07/08) |
PDF | Spanish |
| DWC025 |
Benefit Dispute Settlement
(Rev. 10/05) |
PDF | English |
| DWC025s |
Acuerdo por Disputa de Beneficios
(Rev. 07/08) |
PDF | Spanish |
| DWC026 |
Request for Reimbursement of Payment Made by Health Care Insurer
(Rev. 05/11) |
PDF | English |
| DWC027 |
Designation of Insurance Carrier’s Austin Representative
(Rev. 12/11) |
PDF | English |
| DWC030 |
Austin Representative’s Authorized Designees
(Rev. 12/11) |
PDF | English |
| DWC031 |
Application for Division Approval of Change in the Payment Period and/or Purchase of an Annuity for Death Benefits
(Rev. 10/05) |
PDF | English |
| DWC031s |
Solicitud para Obtener Aprobación por Parte de la División para un Cambio en el Periodo de Pago y/o Compra de una Pensión Para los Beneficios por Causa de Muerte
(Rev. 10/05) |
PDF | Spanish |
| DWC032 |
Request for Designated Doctor Examination
(Rev. 12/10) |
PDF | English |
| DWC032S |
Solicitud para Obtener un Examen por Parte de un Médico Designado
(Rev. 12/10) |
PDF | Spanish |
| DWC033 |
Carrier's Request for Reduction of Income Benefits Due to Contribution
(Rev. 10/05) |
PDF | English |
| DWC035 |
Application for Division Approval of the Purchase of an Annuity for Lifetime Income Benefits
(Rev. 10/05) |
PDF | English |
| DWC041 |
Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease
(Rev. 3/07) |
PDF | English |
| DWC041 |
Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease
(Rev. 3/07) |
WORD | English |
| DWC041S |
Reclamo del Empleado para Compensación por una Lesión Relacionada con el Trabajo o Enfermedad Ocupacional
(Rev. 3/07) |
WORD | Spanish |
| DWC041S |
Reclamo del Empleado para Compensación por una Lesión Relacionada con el Trabajo o Enfermedad Ocupacional
(Rev. 3/07) |
PDF | Spanish |
| DWC042 |
Beneficiary Claim for Death Benefits
(Rev. 4/10) |
PDF | English |
| DWC042 |
Beneficiary Claim for Death Benefits
(Rev. 4/10) |
WORD | English |
| DWC042S |
Reclamación del Beneficiario para Obtener Beneficios por Causa de Muerte
(Rev. 4/10) |
WORD | English |
| DWC042S |
Reclamación del Beneficiario para Obtener Beneficios por Causa de Muerte
(Rev. 4/10) |
PDF | Spanish |
| DWC044 |
Election to Engage in Arbitration
(Rev. 06/12, for disputes filed on or after June 1, 2012) |
PDF | English |
| DWC044 |
Election to Engage in Arbitration
(Rev. 10/05, for disputes filed on or before May 31, 2012) |
PDF | English |
| 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 | Spanish |
| DWC045 |
Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC)
(Rev. 11/11, for use beginning 12/1/11) |
PDF | English |
| DWC045A |
Request for a Medical Contested Case or SOAH Hearing
(Rev. 09/07) |
PDF | English |
| DWC045AS |
Solicitud para una Audiencia para Disputar Beneficios Médicos o Audiencia en la Oficina Estatal de Audiencias Administrativas (SOAH, por sus Siglas en Inglés)
(Rev. 10/07) |
PDF | Spanish |
| 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 | English |
| 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 | Spanish |
| DWC045S |
Solicitud para Programar, Reprogramar, o Cancelar una Conferencia para Revisión de Beneficios (Benefit Review Conference -BRC, por su nombre y siglas en inglés)
(Rev. 11/11, para usarse a partir de 12/1/11) |
PDF | Spanish |
| DWC046 |
Employee's Request for Acceleration of Impairment Income Benefits
(Rev. 10/05) |
PDF | English |
| DWC046S |
Solicitud del Trabajador Lesionado para Recibir un Pago Acelerado de Beneficios por Causa del Impedimento Corporal
(Rev. 10/05) |
PDF | Spanish |
| DWC047 |
Employee’s Request for Advance of Benefits
(Rev. 03/12) |
PDF | English |
| DWC047S |
Solicitud del Empleado para Obtener Beneficios por Adelantado
(Rev. 03/12) |
PDF | Spanish |
| DWC048 |
Request for Travel Reimbursement / Solicitud de Reembolso
(Rev. 06/06) |
PDF | English / Spanish |
| DWC049 |
Request to Schedule a Medical Contested Case Hearing (MCCH)
(Rev. 06/12, for disputes filed on or after June 1, 2012) |
PDF | English |
| 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 | Spanish |
| DWC051 |
Employee's Election for Commuted (Lump Sum) Impairment Income Benefits
(Rev. 11/08) |
PDF | English |
| DWC052 |
Application for Supplemental Income Benefits
(Rev. 04/09) |
PDF | English |
| DWC052S |
Aplicación del trabajador para beneficios de ingresos suplementales
(Rev. 04/09) |
PDF | Spanish |
| DWC053 |
Employee Request to Change Treating Doctor
(Rev. 03/12) |
PDF | English |
| DWC053S |
Solicitud del Empleado para Cambiar de Médico de Tratamiento
(Rev. 03/12) |
PDF | Spanish |
| DWC054 |
Notice to Employee: Intention to Request Division Permission to Adjust Benefits
(Rev. 10/05) |
PDF | English |
| DWC054S |
Aviso al/a la Empleado/a: Intencion de Solicitar permiso a la División para Ajuste de Beneficios
(Rev. 10/05) |
PDF | Spanish |
| DWC055 |
Request to Adjust Average Weekly Wage for Seasonal Employee
(Rev. 10/05) |
PDF | English |
| DWC055S |
Solicitud de Ajuste al Salario Medio Semanal de un(a) Empleado/a de Temporada
(Rev. 10/05) |
PDF | Spanish |
| DWC056 |
Carrier's Request for Seasonal Employee Wage Information from Texas Workforce Commission Records
(Rev. 10/05) |
PDF | English |
| DWC057 |
Request for Extension of Maximum Medical Improvement for Spinal Surgery
(Rev. 10/05) |
PDF | English |
| DWC057s |
Solicitud para Extensión de Mejoramiento Máximo Médico por Cirugía de la Columna Vertebral
(Rev. 07/08) |
PDF | Spanish |
| DWC058 |
Request for Interlocutory Order
(Rev. 09/07) |
PDF | English |
| DWC060 |
Medical Fee Dispute Resolution Request
(Rev. 06/12, for disputes filed on or after June 1, 2012) |
PDF | English |
| DWC060 |
Medical Fee Dispute Resolution Request/Response
(Rev. 02/07, for disputes filed on or before May 31, 2012) |
WORD | English |
| DWC060 |
Medical Fee Dispute Resolution Request/Response
(Rev. 02/07, for disputes filed on or before May 31, 2012) |
PDF | English |
| DWC060s |
Solicitud para Resolución de Disputas por Honorarios Médicos/Respuesta
(Rev. 2/07, for disputes filed on or before May 31, 2012) |
PDF | Spanish |
| 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 | Spanish |
| DWC060S |
Solicitud para Resolución de Disputas por Honorarios Médicos/Respuesta
(Rev. 2/07, for disputes filed on or before May 31, 2012) |
WORD | Spanish |
| DWC062 |
Explanation of Benefits
(Rev. 07/07) |
PDF | English |
| 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 |
| DWC065 |
Application for Inclusion on Registry of Private Providers of Vocational Rehabilitation Services
(Rev. 1/11) |
WORD | English |
| DWC066 |
Statement of Pharmacy Services
(Rev. 12/11) |
PDF | English |
| DWC069 |
Report of Medical Evaluation
(Rev. 6/11) Sample Notice for Health Care Provider (PDF, Word) |
PDF | English |
| DWC070 |
Instructions For Completing The ADA J515 Dental Claim Form For Texas Workers' Compensation Claims
(Rev. 10/05) |
PDF | English |
| DWC073 |
Work Status Report
(Rev. 02/11) |
PDF | English |
| DWC074 |
Description of Injured Employee’s Employment
(Rev. 9/09) |
PDF | English |
| DWC081 |
Agreement Between General Contractor and Sub-Contractor to Provide Worker's Compensation Insurance
(Rev. 10/05) |
PDF | English |
| DWC081S |
Acuerdo Entre el Contratista General y el Sub Contratista
(Rev. 09/07) |
PDF | Spanish |
| DWC082 |
Agreement for Motor Carriers and Owner Operators
(Rev. 10/05) |
PDF | English |
| DWC083 |
Agreement for Certain Building and Construction Workers
(Rev. 10/05) |
PDF | English |
| DWC083S |
Acuerdo para Ciertos Trabajadores de Edificación y Construcción
(Rev. 09/06) |
PDF | Spanish |
| DWC084 |
Exception to Application of Joint Agreement for Certain Building and Construction Workers
(Rev. 10/05) |
PDF | English |
| DWC085 |
Agreement Between General Contractor and Subcontractor to Establish Independent Relationship
(Rev. 10/05) |
PDF | English |
| DWC085S |
Acuerdo Entre el Contratista General y el Sub Contratista Para Establecer una Relación Independiente
|
PDF | Spanish |
| DWC101 |
Program Review Report
(Rev. 08/06) |
WORD | English |
| DWC101 |
Program Review Report
(Rev. 08/06) |
PDF | English |
| DWC102 |
Accident Prevention Plan Cover Sheet
(Rev. 08/06) |
WORD | English |
| DWC102 |
Accident Prevention Plan Cover Sheet
(Rev. 08/06) |
PDF | English |
| DWC103 |
Approved Professional Source Safety Consultant Application
(Rev. 12/06) Note: The Approved Professional Source designation applies only to Loss Control Representatives of Texas Mutual Insurance Company as of September 1, 2005. |
WORD | English |
| DWC104 |
Employer Request for DWC Safety Consultation
(Rev. 08/06) |
WORD | English |
| DWC104 |
Employer Request for DWC Safety Consultation
(Rev. 08/06) |
PDF | English |
| DWC105 |
Accident Prevention Services Worksheet
(Rev. 04/09) |
PDF | English |
| DWC109 |
Accident Prevention Services Annual Report
(Rev. 12/05) |
WORD | English |
| DWC109 |
Accident Prevention Services Annual Report
(Rev. 12/05) |
PDF | English |
| DWC150 |
Notice of Representation or Withdrawal of Representation
(Rev. 10/05) |
PDF | English |
| DWC151 |
Attorney Application for Web Access
(Rev. 10/05) |
PDF | English |
| DWC152 |
Application for Attorney's Fees
(Rev. 10/05) |
PDF | English |
| DWC153 |
Request for Copies of Confidential Claimant Information
(Rev. 10/06) - Effective September 1, 2006, requests for a claim file, medical dispute resolution file, and/or an indemnity resolution file must be made on the newly revised DWC-153 form (10/2006). A requestor must be eligible by statute to receive the |
PDF | English |
| DWC153s |
Solicitud para Obtener Copias de la Información Confidencial del Reclamante
(Rev. 07/08) |
PDF | Spanish |
| DWC155 |
Request for Record Check
(Rev. 10/05) |
PDF | English |
| DWC156 |
Prospective Employment Authorization and Certification
(Rev. 10/05) |
PDF | English |
| DWC156S |
Certificación Y Autorización De Un Posible Empleo
(Rev. 10/06) |
PDF | Spanish |
| DWC205 |
Locations of Employer’s Business(es)
Addendum to DWC Form-005 or DWC Form-020 (Rev. 11/10) |
PDF | English |
| DWC205S |
Locaciones del Negocio(s) del Empleador
Suplemento para el Formulario DWC005 o Formulario DWC020 (Rev. 11/10) |
PDF | Spanish |
| DWC210 |
Surety Bond for Certified Self-Insurance Liabilities
(Rev. 1/06) |
PDF | English |
| DWC210 |
Surety Bond for Certified Self-Insurance Liabilities
(Rev. 1/06) |
WORD | English |
| DWC215 |
Surety Bond Amount Rider
(Rev. 1/06) |
PDF | English |
| DWC215 |
Surety Bond Amount Rider
(Rev. 1/06) |
WORD | English |
| DWC216 |
Surety Bond Name Change Rider
(Rev. 1/06) |
PDF | English |
| DWC216 |
Surety Bond Name Change Rider
(Rev. 1/06) |
WORD | English |
| DWC223 |
Documentary Irrevocable Standby Letter of Credit
(Rev. 01/07) |
PDF | English |
| DWC223 |
Documentary Irrevocable Standby Letter of Credit
(Rev. 01/07) |
WORD | English |
| DWC224 |
Documentary Irrevocable Standby Letter of Credit ("Confirmation")
(Rev. 01/07) |
WORD | English |
| DWC224 |
Documentary Irrevocable Standby Letter of Credit ("Confirmation")
(Rev. 01/07) |
PDF | English |
| DWC225 |
Self-Insurer's Agreement to Post Documentary Irrevocable Standby Letter of Credit
(Rev. 01/07) |
PDF | English |
| DWC225 |
Self-Insurer's Agreement to Post Documentary Irrevocable Standby Letter of Credit
(Rev. 01/07) |
WORD | English |
| DWC226 |
Parental Guaranty
(Rev. 01/07) |
WORD | English |
| DWC226 |
Parental Guaranty
(Rev. 01/07) |
PDF | English |
| DWC227 |
Parental Guaranty for Less than Wholly Owned Subsidiary
(Rev. 01/07) |
WORD | English |
| DWC227 |
Parental Guaranty for Less than Wholly Owned Subsidiary
(Rev. 01/07) |
PDF | English |
| DWC228 |
Power of Attorney
(Rev. 01/07) |
PDF | English |
| DWC228 |
Power of Attorney
(Rev. 01/07) |
WORD | English |
| DWC-EDI-01 |
EDI TRADING PARTNER PROFILE
|
WORD | English |
| EDI-02 |
Insurance Carrier or Trading Partner Medical Electronic Data Interchange (EDI) Profile
(Rev. 06/11) |
PDF | English |
| EDI-03 |
Medical EDI Compliance Coordinator and Trading Partner Notification
(Rev. 06/11) |
PDF | English |
| New Employee Notice English |
New Employee Notice
(covered and non-covered employers shall notify their employees of coverage status, in writing) |
PDF | English |
| New Employee Notice Spanish |
New Employee Notice
(covered and non-covered employers shall notify their employees of coverage status, in writing) |
PDF | Spanish |
| Notice 5 |
Notice to Employees Concerning Workers' Compensation in Texas
(must be posted for employees to read) |
PDF | English |
| Notice 5 Spanish |
Notice to Employees Concerning Workers' Compensation in Texas
(must be posted for employees to read) |
PDF | Spanish |
| Notice 6 |
Notice to Employees Concerning Workers' Compensation in Texas
(must be posted for employees to read) |
PDF | English |
| Notice 6 Spanish |
Notice to Employees Concerning Workers' Compensation in Texas
(must be posted for employees to read) |
PDF | Spanish |
| Notice7e |
Notice to employees concerning Workers' Compensation in Texas
English (Rev. 8/00) |
PDF | English |
| Notice7e |
Notice to employees concerning Workers' Compensation in Texas
English (Rev. 8/00) |
WORD | English |
| Notice7r |
Notice to Certified Self-Insured Employer
Rules (Rev. 7/94) |
WORD | English |
| Notice7r |
Notice to Certified Self-Insured Employer
Rules (Rev. 7/94) |
PDF | English |
| Notice7s |
Notice to employees concerning Workers' Compensation in Texas
Spanish (Rev. 8/00) |
WORD | Spanish |
| Notice7s |
Notice to employees concerning Workers' Compensation in Texas
Spanish (Rev. 8/00) |
PDF | Spanish |
| Notice 8 English |
Required Workers' Compensation Coverage
(building or construction projects for governmental entities) |
PDF | English |
| Notice 8 Spanish |
Required Workers' Compensation Coverage
(building or construction projects for governmental entities) |
PDF | Spanish |
| Notice 9 English |
Notice Regarding Certain Work-Related Communicable Diseases and Eligibility for Workers' Compensation Benefits
(law enforcement officers, fire fighters, emergency medical service employees, paramedics, and correctional officers) |
PDF | English |
| Notice 9 Spanish |
Notice Regarding Certain Work-Related Communicable Diseases and Eligibility for Workers' Compensation Benefits
(law enforcement officers, fire fighters, emergency medical service employees, paramedics, and correctional officers) |
PDF | Spanish |
| PLN01 |
Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d))
(Rev. 10/05) |
WORD | English |
| PLN01 |
Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d))
(Rev. 10/05) |
PDF | English |
| PLN01S |
Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d))
(Rev. 01/10) |
WORD | Spanish |
| PLN02 |
Notification of First Temporary Income Benefit Payment (124.2(e)(1))
(Rev. 10/05) |
PDF | English |
| PLN02 |
Notification of First Temporary Income Benefit Payment (124.2(e)(1))
(Rev. 10/05) |
WORD | English |
| PLN02S |
Notification of First Temporary Income Benefit Payment (124.2(e)(1))
(Rev. 01/10) |
WORD | Spanish |
| PLN03 |
Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5))
(Rev. 10/05) |
WORD | English |
| PLN03 |
Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5))
(Rev. 10/05) |
PDF | English |
| PLN03S |
Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5))
(Rev. 01/10) |
WORD | Spanish |
| PLN04 |
Notification of First Lifetime Income Benefit Payment (124.2(e)(1))
(Rev. 10/05) |
WORD | English |
| PLN04 |
Notification of First Lifetime Income Benefit Payment (124.2(e)(1))
(Rev. 10/05) |
PDF | English |
| PLN04S |
Notification of First Lifetime Income Benefit Payment (124.2(e)(1))
(Rev. 01/10) |
WORD | Spanish |
| PLN05 |
Notification of First Death Benefit Payment (124.2(e)(1))
(Rev. 10/05) |
WORD | English |
| PLN05 |
Notification of First Death Benefit Payment (124.2(e)(1))
(Rev. 10/05) |
PDF | English |
| PLN05S |
Notification of First Death Benefit Payment (124.2(e)(1))
(Rev. 01/10) |
WORD | Spanish |
| PLN06 |
Notification of Employer Full Salary Payment (124.2(e)(7))
(Rev. 10/05) |
WORD | English |
| PLN06 |
Notification of Employer Full Salary Payment (124.2(e)(7))
(Rev. 10/05) |
PDF | English |
| PLN06S |
Notification of Employer Full Salary Payment (124.2(e)(7))
(Rev. 01/10) |
WORD | Spanish |
| PLN07 |
Notification of Change of Indemnity Benefit Type (124.2(e)(4))
(Rev. 10/05) |
PDF | English |
| PLN07 |
Notification of Change of Indemnity Benefit Type (124.2(e)(4))
(Rev. 10/05) |
WORD | English |
| PLN07S |
Notification of Change of Indemnity Benefit Type (124.2(e)(4))
(Rev. 01/10) |
WORD | Spanish |
| PLN08 |
Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3))
(Rev. 10/05) |
WORD | English |
| PLN08 |
Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3))
(Rev. 10/05) |
PDF | English |
| PLN08S |
Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3))
(Rev. 01/10) |
WORD | Spanish |
| PLN09 |
Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6))
(Rev. 10/05) |
WORD | English |
| PLN09 |
Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6))
(Rev. 10/05) |
PDF | English |
| PLN09S |
Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6))
(Rev. 01/10) |
WORD | Spanish |
| PLN10 |
Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5))
(Rev. 10/05) |
WORD | English |
| PLN10 |
Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5))
(Rev. 10/05) |
PDF | English |
| PLN10S |
Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5))
(Rev. 01/10) |
WORD | Spanish |
| PLN11 |
Notice of Disputed Issues(s) and Refusal to Pay Benefits (124.2(h))
(Rev. 10/05) |
WORD | English |
| PLN11 |
Notice of Disputed Issues(s) and Refusal to Pay Benefits (124.2(h))
(Rev. 10/05) |
PDF | English |
| PLN11S |
Notice of Disputed Issues(s) and Refusal to Pay Benefits (124.2(h))
(Rev. 01/10) |
WORD | Spanish |
| Sample Notice |
Aviso de Pago Insuficiente de los Beneficios de Ingresos
(Rev. 12/11) |
PDF | Spanish |
| Sample Notice |
Notice of Underpayment of Income Benefits
(Rev. 12/11) |
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 |
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 | Spanish |
