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Workers' compensation medical forms

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TDI Form Number Description File Format Language
DWC044 Election to Engage in Arbitration
Rev. 06/12 		PDF English
DWC044S Elección para Participar en un Arbitraje
Rev. 05/12 		PDF Spanish
DWC045M Request to schedule, reschedule, or cancel a benefit review conference to appeal a medical fee dispute decision (BRC-MFD)
Rev. 07/21 		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
Rev. 07/21 		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. 02/21 		PDF English
DWC060S Solicitud para Resolución de Disputas por Honorarios Médicos
Rev. 02/21 		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. 4/23, for use on or after 4/30/2023 		PDF English
DWC068 Designated doctor examination data report
Rev. 6/23, for use on or after 6/5/2023 		PDF English
DWC069 Report of Medical Evaluation
Rev. 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. 09/19 		PDF English
DWC073s Reporte de Estado de Trabajo
Rev. 09/19 		PDF Spanish
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 Solicitud para una revisión por parte de una Organización de Revisión Independiente
[En Español] - Solicitud para pedir una revisión por parte de una Organización de Revisión Independiente (Independent Review Organization- IRO por su nombre y siglas en inglés) para las disputas médicas necesarias de pacientes, empleados lesionados, representantes del paciente o proveedores de atención médica. 		PDF Spanish

For more information, contact: WebStaff@tdi.texas.gov