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BWC # Form Title Description View/ Print Online Order
COVERMedical Documentation Fax Cover Sheet pdf Print   
C-5Application for Death Benefits and/or Funeral ExpensesDescription pdf Print  
C-5-ESSolicitud para los beneficios por fallecimiento y/o gastos funerariosDescription pdf Print   
C-9Request for Medical Service Reimbursement or Recommendation for Additional Conditions for Industrial Injury or Occupational DiseaseDescription pdf Print  
C-9-ARequest for Additional Medical Documentation for C-9Description pdf Print  
C-9-A PsychRequest for Additional Medical Documentation for C-9 Psychological ServicesDescription pdf Print  
C-11ADR Appeal to the MCO Medical Treatment/Service DecisionDescription pdf Print Online Form 
C-11-ESApelación a la decisión por servicio/tratamiento médico de la MCO de ADRDescription pdf Print   
C-17Request for Injured Worker Outpatient Medication ReimbursementDescription pdf Print  
C-30Request for Medical InformationDescription pdf Print   
C-101Authorization to Release Medical InformationDescription pdf Print  
C-101-ESAutorización para divulger información médica pdf Print   
C-140Initial Application for Wage Loss CompensationDescription pdf Print Online Form 
C-143DEP Physician's Report of Work Ability pdf Print  
C-143 PCDisability Evaluator Panel (DEP) Physician's Report of Work Ability Cognitive/Psychological Conditions pdf Print   
C-190Justification of Necessity for Seating/Wheeled MobilityDescription pdf Print   
C-196Amputation/Loss of Use Diagram pdf Print   
ECP-TXPhysician's Treatment Request pdf Print   
FEEBWC Fee Schedule  Online Form  
FROIFirst Report of an Injury, Occupational Disease or DeathDescription pdf Print Online Form 
FROI-ESInforme inicial de lesión, enfermedad ocupacional o fallecimientoDescription pdf Print   
Reporting fraudDescription  Online Form  
MEDCO-12Request to Change Provider Information pdf Print   
MEDCO-13Application for Provider Enrollment and Certification pdf Print Online Form  
MEDCO-13AApplication for Provider Enrollment Non-Certification pdf Print Online Form  
MEDCO-13BApplication for Provider Recertification pdf Print   
MEDCO-14Physician's Report of Work AbilityDescription pdf Print  
MEDCO-15Medco 15 - Non certified enrollment application (For MCO Use Only)  Online Form  
MEDCO-16Mental Health Notes Summary pdf Print  
MEDCO-17Transitional Work Grant Program Job Analysis Template Form pdf Print   
MEDCO-17SSupplemental Job Analysis Template Forms pdf Print   
MEDCO-22Medication Physician Review pdf Print   
MEDCO-30Disability Evaluator ApplicationDescription pdf Print   
MEDCO-31Request for Prior Authorization of Medication FormDescription pdf Print   
MEDCO-34MCO Request for Drug Utilization Review pdf Print   
MEDCO-35Formulary Medication Request FormDescription pdf Print   
MEDCO-38Certification Agreement Between the Injured Worker and Service Provider (Contractor) pdf Print   
MEDCO-43Caregiver Services Physician's Evaluation Report pdf Print   
RH-1Rehabilitation AgreementDescription pdf Print  
RH-5Employer/Trainer's ReportDescription pdf Print  
RH-6On-the-Job Training AgreementDescription pdf Print  
RH-7Loan/Release Agreement for Tools and EquipmentDescription pdf Print  
RH-8Vocational Rehabilitation Closure Report - AddendumDescription pdf Print   
RH-13Work Trial Agreement pdf Print   
RH-14Job Modification Agreement - Supplier Reimbursement pdf Print   
RH-15Job Modification Agreement - Return-to-Work (RTW) Employer pdf Print   
RH-18Authorization for Living Maintenance Wage LossDescription pdf Print  
RH-19Employer Incentive ContractDescription pdf Print  
RH-21Vocational Rehabilitation Closure ReportDescription pdf Print   
RH-24Gradual Return to Work Contract Reimbursement MethodDescription pdf Print  
RH-42Vocational Rehabilitation Initial Assessment Report pdf Print   
RH-43Vocational Rehabilitation Assessment Plan pdf Print   
RH-44Vocational Rehabilitation Comprehensive Plan pdf Print   
RH-45Authorization Request for Vocational Rehabilitation Plan pdf Print   
RH-46Vocational Rehabilitation Progress Report pdf Print   
RH-47Vocational Rehabilitation Job Retention Plan pdf Print   
RH-94AReport of Earnings for Living Maintenance Wage Loss Compensation pdf Print   
Subrogation Referral Form pdf Print   
TWD-115Transitional Work Developer's ApplicationDescription pdf Print   
TWD-116Transitional Work Developer's Reaccreditation ApplicationDescription pdf Print