| DWC Form# |
Form Description |
Link |
| 022 |
Required Medical examination |
http://www.tdi.state.tx.us/forms/dwc/dwc022rme.pdf |
| 024 |
Benefit Dispute Agreement |
http://www.tdi.state.tx.us/forms/dwc/dwc24.pdf |
| 025 |
Benefit dispute settlement |
http://www.tdi.state.tx.us/forms/dwc/dwc25.pdf |
| 032 |
Request for a designated Doctor |
http://www.tdi.state.tx.us/forms/dwc/dwc032desdoc.pdf |
| 041 |
Employee’s claim for compensation |
http://www.tdi.state.tx.us/forms/dwc/dwc041firstrpt.pdf |
| 045 |
Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC) |
http://www.tdi.texas.gov/forms/dwc/dwc045brc.pdf |
| 046 |
Employee’s request for acceleration of impairment income benefits |
http://www.tdi.state.tx.us/forms/dwc/dwc46.pdf |
| 047 |
Employee’s Request for payment of Advanced Compensation |
http://www.tdi.state.tx.us/forms/dwc/dwc47.pdf |
| 048 |
Employees request for travel reimbursement |
http://www.tdi.state.tx.us/forms/dwc/dwc048trvlreim.pdf |
| 051 |
Employee’s election for lump sum impairment income benefits |
http://www.tdi.state.tx.us/forms/dwc/dwc051iibs.pdf |
| 052 |
application for supplemental income benefits |
http://www.tdi.state.tx.us/forms/dwc/dwc052sibs.pdf |
| 053 |
Employee’s request to change treating doctors-snon network |
http://www.tdi.state.tx.us/forms/dwc/dwc053chngdoc.pdf |
| 069 |
Maximum Medical improvement & impairment rating form |
http://www.tdi.state.tx.us/forms/dwc/dwc069medrpt.pdf |
| 073 |
Work Status Report, Filled by all doctors involved in the injured workers care |
http://www.tdi.state.tx.us/forms/dwc/dwc073wkstat.pdf |
| 074 |
used by the doctor to see if the injured worker can return to work in a modified duty |
http://www.tdi.state.tx.us/forms/dwc/dwc074desc.pdf |
| 0150 |
Notice of representation or withdrawal or representation |
http://www.tdi.state.tx.us/forms/dwc/dwc150.pdf |
| 0151 |
Attorney application for web access |
http://www.tdi.state.tx.us/forms/dwc/dwc151.pdf |
| 0152 |
application for attorney fee |
http://www.tdi.state.tx.us/forms/dwc/dwc152attyfee.pdf |
| LHL009 |
Request for review by an independent review organization |
http://www.tdi.state.tx.us/forms/lhlhmo/lhl009urairoreq.pdf |
