DWC020A
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Correction/Revision/Endorsement to Existing Policy Rev. 10/05
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PDF |
English |
DWC020SI
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Self-Insured Governmental Entity Coverage Information Rev. 08/12 - Using Google Chrome or Mozilla Firefox to file electronically? See more at “Electronic Filing - Online Forms” above.
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PDF |
English |
DWC022
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Required Medical Examination (RME) - Request for Agreement / Request for Order Rev. 7/11
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PDF |
English |
DWC022S
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Examen Médico Requerido (Required Medical Examination –RME, por su nombre y siglas en inglés) – Solicitud para un Acuerdo / Solicitud para una Orden
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PDF |
Spanish |
DWC024
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Benefit Dispute Agreement Rev. 11/17
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PDF |
English |
DWC024s
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Acuerdo para Disputa de Beneficios Rev. 11/17
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PDF |
Spanish |
DWC025
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Benefit Dispute Settlement Rev. 11/17
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PDF |
English |
DWC025s
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Acuerdo por Disputa de Beneficios Rev. 11/17
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PDF |
Spanish |
DWC026
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Request for Reimbursement of Payment Made by Health Care Insurer Rev. 01/15
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PDF |
English |
DWC027
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Designation of insurance carrier’s Austin representative Rev. 03/22
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PDF |
English |
DWC029
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Request for standard detailed data reports Rev. 03/22
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PDF |
English |
DWC031
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Application for Division Approval of Change in the Payment Period and/or Purchase of an Annuity for Death Benefits Rev. 02/17
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PDF |
English |
DWC031s
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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. 02/17
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PDF |
Spanish |
DWC032
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Request for Designated Doctor Examination Rev. 10/18
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PDF |
English |
DWC032S
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Solicitud para Obtener un Examen por Parte de un Médico Designado Rev. 10/18
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PDF |
Spanish |
DWC033
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Request to reduce income benefits due to contribution Rev. 05/22
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PDF |
English |
DWC035
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Application for Division Approval of the Purchase of an Annuity for Lifetime Income Benefits Rev. 02/17
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PDF |
English |
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 |
DWC045
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Request to schedule, reschedule, or cancel a benefit review conference (BRC) Rev. 07/21
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PDF |
English |
DWC045A
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Request for a Medical Contested Case or SOAH Hearing Rev. 09/07, applicable only to medical disputes that were filed prior to June 1, 2012
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PDF |
English |
DWC045AS
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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, aplicable solamente para las disputas médicas que fueron presentadas antes del 1º de junio del 2012
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PDF |
Spanish |
DWC045S
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Solicitud para programar, reprogramar, o cancelar una conferencia para revisión de beneficios (benefit review conference –BRC, por su nombre y siglas en inglés) Rev. 07/21
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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 |
DWC057
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Request for Extension of Maximum Medical Improvement Date for Spinal Surgery Rev. 02/17
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PDF |
English |
DWC057S
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Solicitud para Extensión de la Fecha para el Mejoramiento Máximo Médico (Maximum Medical Improvement -MMI, por su nombre y siglas en inglés) por una Cirugía de la Columna Vertebral Rev. 02/17
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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 |
DWC095
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SIF Reimbursement Request Form - Overturned Order or Designated Doctor Opinion Rev. 01/21
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PDF |
English |
DWC096
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SIF Reimbursement Request Form – Refund of Death Benefits Rev. 01/21
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PDF |
English |
DWC097
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SIF Reimbursement Request Form – Multiple Employment Rev. 01/21
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PDF |
English |
DWC098
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SIF Reimbursement Request Form – Pharmaceutical Rev. 01/21
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PDF |
English |
DWC105
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Accident prevention services worksheet Rev. 11/21
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PDF |
English |
DWC105
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Accident prevention services worksheet Rev. 11/21
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WORD |
English |
DWC109
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Accident prevention services annual report Rev. 11/21
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PDF |
English |
DWC109
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Accident prevention services annual report Rev. 11/21
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WORD |
English |
DWC121
|
Claim Administration Contact Information Rev. 3/20
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PDF |
English |
DWC154
|
Workers' Compensation Complaint Form Rev. 03/16
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PDF |
English |
EDI-01
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Electronic data interchange (EDI) trading partner profile Rev. 04/22
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PDF |
English |
EDI-02
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Insurance carrier or trading partner medical electronic data interchange (EDI) profile Rev. 04/22
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PDF |
English |
EDI-03
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Claim and medical EDI compliance coordinator and medical EDI trading partner notification Rev. 02/22
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PDF |
English |