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BWC #
Form Title
Description
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COVER
Medical Documentation Fax Cover Sheet
 
 
 
 
C-5
Application for Death Benefits and/or Funeral Expenses
 
 
 
C-5-ES
Solicitud para los beneficios por fallecimiento y/o gastos funerarios
 
 
 
 
C-9
Request for Medical Service Reimbursement or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease
 
 
 
C-9-A
Request for Additional Medical Documentation for C-9
 
 
 
C-9-A Psych
Request for Additional Medical Documentation for C-9 Psychological Services
 
 
 
C-11
ADR Appeal to the MCO Medical Treatment/Service Decision
 
 
 
C-11-ES
Apelación a la decisión por servicio/tratamiento médico de la MCO de ADR
 
 
 
 
C-17
Request for Injured Worker Outpatient Medication Reimbursement
 
 
 
C-30
Request for Medical Information
 
 
 
 
C-101
Authorization to Release Medical Information
 
 
 
C-101-ES
Autorización para divulger información médica
 
 
 
 
C-140
Initial Application for Wage Loss Compensation
 
 
 
C-143
DEP Physician's Report of Work Ability
 
 
 
C-143 PC
Disability Evaluator Panel (DEP) Physician's Report of Work Ability Cognitive/Psychological Conditions
 
 
 
 
C-190
Justification of Necessity for Seating/Wheeled Mobility
 
 
 
 
C-196
Amputation/Loss of Use Diagram
 
 
 
 
ECP-TX
Physician's Treatment Request
 
 
 
 
FEE
BWC Fee Schedule
 
 
 
 
FROI
First Report of an Injury, Occupational Disease or Death
 
 
 
FROI-ES
Informe inicial de lesión, enfermedad ocupacional o fallecimiento
 
 
 
 
Reporting fraud
 
 
 
 
MEDCO-12
Request to Change Provider Information
 
 
 
 
MEDCO-13
Application for Provider Enrollment and Certification
 
 
 
 
MEDCO-13A
Application for Provider Enrollment Non-Certification
 
 
 
 
MEDCO-13B
Application for Provider Recertification
 
 
 
 
MEDCO-14
Physician's Report of Work Ability
 
 
 
MEDCO-15
Medco 15 - Non certified enrollment application (For MCO Use Only)
 
 
 
 
MEDCO-16
Mental Health Notes Summary
 
 
 
MEDCO-17
Transitional Work Grant Program Job Analysis Template Form
 
 
 
 
MEDCO-17S
Supplemental Job Analysis Template Forms
 
 
 
 
MEDCO-22
Medication Physician Review
 
 
 
 
MEDCO-30
Disability Evaluator Application
 
 
 
 
MEDCO-31
Request for Prior Authorization of Medication Form
 
 
 
 
MEDCO-34
MCO Request for Drug Utilization Review
 
 
 
 
MEDCO-35
Formulary Medication Request Form
 
 
 
 
MEDCO-38
Certification Agreement Between the Injured Worker and Service Provider (Contractor)
 
 
 
 
MEDCO-43
Caregiver Services Physician's Evaluation Report
 
 
 
 
RH-1
Rehabilitation Agreement
 
 
 
RH-5
Employer/Trainer's Report
 
 
 
RH-6
On-the-Job Training Agreement
 
 
 
RH-7
Loan/Release Agreement for Tools and Equipment
 
 
 
RH-8
Vocational Rehabilitation Closure Report - Addendum
 
 
 
 
RH-13
Work Trial Agreement
 
 
 
 
RH-14
Job Modification Agreement - Supplier Reimbursement
 
 
 
 
RH-15
Job Modification Agreement - Return-to-Work (RTW) Employer
 
 
 
 
RH-18
Authorization for Living Maintenance Wage Loss
 
 
 
RH-19
Employer Incentive Contract
 
 
 
RH-21
Vocational Rehabilitation Closure Report
 
 
 
 
RH-24
Gradual Return to Work Contract Reimbursement Method
 
 
 
RH-42
Vocational Rehabilitation Initial Assessment Report
 
 
 
 
RH-43
Vocational Rehabilitation Assessment Plan
 
 
 
 
RH-44
Vocational Rehabilitation Comprehensive Plan
 
 
 
 
RH-45
Authorization Request for Vocational Rehabilitation Plan
 
 
 
 
RH-46
Vocational Rehabilitation Progress Report
 
 
 
 
RH-47
Vocational Rehabilitation Job Retention Plan
 
 
 
 
RH-94A
Report of Earnings for Living Maintenance Wage Loss Compensation
 
 
 
 
Subrogation Referral Form
 
 
 
 
TWD-115
Transitional Work Developer's Application
 
 
 
 
TWD-116
Transitional Work Developer's Reaccreditation Application