Solutions
Discover
Links
WC program management forms (CA)
- Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility
- Employers’ Report of Occupational Injury and Illness – Form 5020
- Notice of Personal Chiropractor or Personal Acupuncturist
- Pre-Designation of Personal Physician
- Time of Hire Pamphlet
- Medical Service Order Form
- Offer of Medical Treatment Form
- Verification of Receipt Form - First Aid
- Verification of Receipt Form - Worker’s Compensation Claim
CA MPN Documents
Texas HCN Documents
- Employee Notice of Network Requirements - English
- Employee Notice of Network Requirements - Spanish
- Workers' Compensation Network Acknowledgement
- Out-of-Network Treating Doctor Request Form
- Out-of-Network Referral Request
- Non-Primary Care Treating Doctor Request
- Non-Primary Care Treating Doctor Request Form
- Complaint Form
- Compkey+ Network Service Areas
- Compkey+ Certified Counties
- CompKey Plus NNR Tracking Log
- Change-of-Network Treating Doctor Request Form
Specialized Loss Adjusting
Ohio Workers' Compensation
- Permanent Authorization (AC-2)
- Authorization to Release Medical Information (C-101)
- Application for Wage Loss Compensation (C-140)
- Notice to Change Physician of Record (C-23)
- Request for Temporary Total Compensation (C-84)
- Completion of a Motion (C-86)
- Wage Statement (Wages-EMP)
- Physician’s Request (C-9)
- First Report of an Injury, Occupational Disease or Death (FROI)