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Saturday, April 20, 2024 -
WCC PDF Forms
| Form Name | Form 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 report | QME 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 Facilities | Appendix A |
| Appendix C: Ratios Applied To Revise Certain DRG Weights In California | Appendix C |
| Application for accreditation or re-accreditation as education provider | QME Form 118 |
| Application for Appointment as Qualified Medical Evaluator | QME 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 Form | Form 10297 |
| Audit Referral Form (06-2006) | DWC-AU-906 |
| Billing and Statement of Charges for Medical-Legal Reports | IMC-76 |
| Choosing Medical Care For Work Related Injuries and Illnesses | DW 1194 |
| Cover Page for Medical Provider Network Application | DWC 97674 |
| Declaration Regarding Protection of Mental Health Record | QME Form 121 |
| Doctor's First Report Of Occupational Injury Or Illness | 5021 |
| Election for High Cost Outlier | DWC 15 |
| Employee's Request For Informal Permanent Disability Rating | DEU 200 |
| Faculty Disclosure of Commercial Interest | QME Form 119 |
| Finding and Order (Replacement QME Represented) |
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