DWC044
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Election to Engage in Arbitration Rev. 06/12
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PDF |
English |
DWC044S
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Elección para Participar en un Arbitraje Rev. 05/12
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PDF |
Spanish |
DWC045M
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Request to schedule, reschedule, or cancel a benefit review conference to appeal a medical fee dispute decision (BRC-MFD) Rev. 07/21
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PDF |
English |
DWC045MS
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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
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PDF |
Spanish |
DWC049
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Request to Schedule a Medical Contested Case Hearing (MCCH) Rev. 11/17
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PDF |
English |
DWC049S
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Solicitud para Programar una Audiencia para Disputar Beneficios Médicos (Medical Contested Case Hearing –MCCH, por su nombre y siglas en inglés) Rev. 11/17
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PDF |
Spanish |
DWC060
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Medical Fee Dispute Resolution Request Rev. 02/21
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PDF |
English |
DWC060S
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Solicitud para Resolución de Disputas por Honorarios Médicos Rev. 02/21
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PDF |
Spanish |
DWC064
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Medical Interlocutory Order Request - Continued Use of a Drug Previously Prescribed and Dispensed and Excluded from TDI-DWC’s Closed Formulary Rev. 8/11
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PDF |
English |
DWC066
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Statement of Pharmacy Services Rev. 12/11
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PDF |
English |
DWC067
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Designated doctor certification application Rev. 4/23, for use on or after 4/30/2023
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PDF |
English |
DWC068
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Designated doctor examination data report Rev. 6/23, for use on or after 6/5/2023
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PDF |
English |
DWC069
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Report of Medical Evaluation Rev. 1/15
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PDF |
English |
DWC070
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Instructions For Completing The ADA J515 Dental Claim Form For Texas Workers' Compensation Claims Rev. 10/05
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PDF |
English |
DWC072
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Medical Quality Review Panel Application Rev. 01/13
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PDF |
English |
DWC073
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Work Status Report Rev. 09/19
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PDF |
English |
DWC073s
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Reporte de Estado de Trabajo Rev. 09/19
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PDF |
Spanish |
DWC074
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Description of Injured Employee’s Employment Rev. 9/09
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PDF |
English |
DWC154
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Workers' Compensation Complaint Form Rev. 03/16
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PDF |
English |
LHL009
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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
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PDF |
English |
LHL009 Spanish
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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.
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PDF |
Spanish |