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Worker’s Comp Forms

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
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