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WCC PDF Forms

Form NameForm Number
Finding and Order (Replacement QME Unrepresented)
Finding and Order RE: Second QME Panel (Unrepresented Case)
Finding and Order RE:Second QME Panel (represented case)
General Information and Instructions, Effective for Dates of Service on or after January 1, 20049789.11(a)(1)
General Information and Instructions, Effective for Dates of Service on or after July 1, 20049789.11(a)(1)
Getting Appropriate Medical Care for Your Injury (October 2006)
Glossary of workers' compensation terms for injured workers (07-2005)Fact Sheet B
Glossary of workers' compensation terms for injured workers - Spanish (09-2005)Fact Sheet B
HCO Enrollment FormWC-HCO1
How to file a complaint with the Audit Unit (06-2006)DWC-AU-905
How to Request A QME-If you do not have a lawyerIMC 105
Independent medical review application
Medical Mileage Expense Form (01-2009)I&A mileage form
Medical Mileage Expense Form (06-2011)
Medical Mileage Expense Form - English and Spanish (01-2008)
Medical mileage expense form in English/Spanish - for travel between 07-01-2006 and 01-01-2007IA mileage form
Medical mileage expense form in English/Spanish - for travel on or after 01-01-2007IA mileage form
NOTICE OF OFFER OF REGULAR WORK (for injuries aft 1/1/05)DWC-AD 10003
NOTICE OF PERSONAL CHIROPRACTOR OR PERSONAL ACUPUNCTURISTDWC 9783.1
Notice of pre-designation of personal physician - Spanish (03-2007)DWC 9783
Notice of QME UnavailabilityIMC-12210
Official Medical Fee Schedule order formomfsord
Order for Panel QME 8 CCR Section 32.1(C)(Represented)
Petition for Resolution of Reimbursment DisputeAHCA Form 3160-0023
Physician Contract Application (Independant Medical Reviewer) 05-2007DWC 9768.5
Pre-Trial Conference Statement (Liens)Pre-Trial
Predesignation of Personal Physician (03-01-2007)DWC 9783
Primary treating physician's permanent and stationary report - 1997 permanent disability rating schedule (06-2005)DWC PR-3
Primary treating physician's permanent and stationary report - 2005 permanent disability rating schedule (06-2005)DWC PR-4
Primary treating physician's progress report (6-2005)DWC PR-2

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