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WCC PDF Forms

Form NameForm Number
9792.1 Appendix B (DRG Weights and Revised DRG Weights)Appendix B
A Guidebook for Injured Workers, 3rd Ed. (Nov. 2006)
A Guidebook for Injured Workers, 3rd Ed. - Spanish (Nov. 2006)
AME or QME declaration of service of medical - legal reportQME Form 122
Answers to your questions about permanent disability benefits (12-2005)Fact Sheet D
Answers to your questions about permanent disability benefits - Spanish (01-2006)Fact Sheet D
Answers to your questions about qualified medical evaluators and agreed medical evaluators (12-2005)Fact Sheet E
Answers to your questions about qualified medical evaluators and agreed medical evaluators - Spanish (04-2007)Fact Sheet E
Answers to your questions about temporary disability benefits (12-2005)Fact Sheet C
Answers to your questions about temporary disability benefits - Spanish (01-2006)Fact Sheet C
Answers to your questions about utilization review (01-2006)Fact Sheet A
Answers to your questions about utilization review - Spanish (08-2006)Fact Sheet A
Appendix A: Payment Of Inpatient Services Of Health FacilitiesAppendix A
Appendix C: Ratios Applied To Revise Certain DRG Weights In CaliforniaAppendix C
Application for accreditation or re-accreditation as education providerQME Form 118
Application for Appointment as Qualified Medical EvaluatorQME Form 100
Application for discrimination benefits pursuant to Labor Code section 132(A)
Application for Spinal Surgery 2nd Opinion Physician List (05/2007)Form 232
Apportionment (01-01-2005)DEU 105
Arbitrator Submittal FormForm 10297
Audit Referral Form (06-2006)DWC-AU-906
Billing and Statement of Charges for Medical-Legal ReportsIMC-76
Choosing Medical Care For Work Related Injuries and IllnessesDW 1194
Cover Page for Medical Provider Network ApplicationDWC 97674
Declaration Regarding Protection of Mental Health RecordQME Form 121
Doctor's First Report Of Occupational Injury Or Illness5021
Election for High Cost OutlierDWC 15
Employee's Request For Informal Permanent Disability RatingDEU 200
Faculty Disclosure of Commercial InterestQME Form 119
Finding and Order (Replacement QME Represented)

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