| Description | File Format |
|---|---|
| Workers' Compensation Complaint Form | HTML |
| Employee Acknowledgment Form Samples | HTML |
Workers' Compensation Health Care Networks Forms
If the form is a fillable PDF, learn how to enable all fillable form features.
| TDI Form Number | Description | File Format | Language |
|---|---|---|---|
| LHL705 |
Workers’ Compensation Health Care Network Application |
English | |
| LHL708 |
Workers' Compensation Network Access Plan Checklist WC Network Access Plan Checklist |
English | |
| LHL720 |
Workers' Compensation Health Care Network Provider Contract Checklist |
English | |
| LHL721 |
Workers’ Compensation Network Contract with Insurance Carrier Contract Requirements Checklist |
English | |
| LHL722 |
Workers' Compensation Health Care Network Management Contract Checklist |
English | |
| SN003 |
Workers Comp Network Sample Contingency Plan |
English | |
| SN008 |
Workers Comp Network Sample QI Report |
English |
For more information, contact: MCQA@tdi.texas.gov