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DRESS EMPLOYER: EMPLOYER S ADDRESS: CLAIMS ADMINISTRATOR: CLAIMS ADMINISTRATOR S ADDRESS: CLAIMS ADMINISTRATOR S CLAIM NUMBER(S): NAME OF PRIMARY TREATING PHYSICIAN PRIMARY TREATING PHYSICIAN S ADDRESS: PHYSICIAN PANEL: List below the NAMES, ADDRESSES and MEDICAL SPECIALTIES (e.g.-orthopedics, cardiology, etc.) of a panel of FIVE (5) physicians (to include one chiropractor if the employee is being treated by a chiropractor) available to provide treatment of the employee s injury.

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A DWC-3 is an Employer's Wage Statement form outlined by the Texas Department of Insurance, Division of Workers' Compensation (DWC). Texas Mutual uses this form to determine the injured employee's average weekly wage and calculate financial assistance for them or their beneficiary.

Overview: The Request for Authorization for Medical Treatment (DWC Form RFA) is required for the employee's treating physician to initiate the utilization review process required by Labor Code section 4610.

Resource Family Approval Program (RFA) Unifies approval standards for all caregivers, regardless of the child's case plan.

Division of Workers' Compensation (DWC)

Your DWC-1 claim form is your declaration that you have been injured while working, and that you believe you require compensation while you recover. A common misconception is that going to the doctor – something you should doas soon as possible – essentially creates a workers' comp claim for you.

DWC-7 Notice to Employees-Injuries Caused by Work (English and Spanish). This form provides your employees with information regarding workers' compensation benefits and the Medical Provider Network (MPN) in California.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232