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Claims Forms

Alabama

Authorization to Disclose Health Information

Claims Summary Form (WC 4)

First Report of Injury (WCC 2)

Injury Statement in Your Own Words

Job Analysis/Physical Demands

Supplementary Report (WC 3)

Travel Expense Reimbursement

Workers’ Compensation Temporary Prescription ID Card

Access Alabama Claims ID cards

Arkansas

Job Analysis/Physical Demands

Notice of Injury (AR-N)

Travel Expense Reimbursement

Wage Statement (AR-W)

Workers’ Comp Instructions (AR-P)

Workers’ Compensation Temporary Prescription ID Card

Access Arkansas Claims ID cards

Florida

General Forms

Authorization and Request for Unemployment Compensation Information (DWC-30)

Authorization to Disclose Health Information

Employee Earnings Report (DWC-19)

False or Fraudulent Claim Warning

First Report of Injury (DWC-1)

Florida Workers’ Compensation Uniform Medical Treatment/Status Reporting Form with Instructions (DWC-25)

Injury Statement in Your Own Words

Job Analysis/Physical Demands

Permanent Total Supplemental Worksheet (DWC-35)

Request for Social Security Disability Benefit Information (DWC-14)

Statement of Charges for Drugs and Medical Equipment and Supplies (DWC-10)

Statement of Quarterly Earnings (DWC-40)

Travel Expense Reimbursement Form

Wage Statement (DWC-1a)

Workers’ Compensation Temporary Prescription ID Card

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Georgia

Authorization and Consent to Release Medical Information (WC-207)

Case Progress Report (WC-4)

First Report of Injury (WC-1)

Injury Statement in Your Own Words

Job Analysis (WC-240A)

Notice of Offer of Suitable Employment (WC-240)

Notice of Payment or Suspension of Benefits (WC-2)

Notice to Employee of Medical Release to Return to Work with Restrictions or Limitations (WC-104)

Notice to Controvert (WC-3)

Travel Expense Reimbursement Form

Wage Documentation (WC-262)

Wage Statement (WC-6)

Workers’ Compensation Temporary Prescription ID Card

Workers’ Compensation Treatment Plan

Access Georgia Claims ID cards

Illinois

Authorization to Use or Disclose Protected Health Information

Injury Statement in your own words

Job Analysis/Physical Demands

First report of injury

Indiana

Authorization to Disclose Health Information

First Report of Injury

Injury Statement in Your Own Words

Job Analysis/Physical Demands

Travel Expense Reimbursement

Workers’ Compensation Temporary Prescription ID Card

Workers’ Compensation Treatment Plan

Access Indiana Claims ID cards

Kentucky

General Forms

False or Fraudulent Claim Warning

First Report of Injury (IA-1)

Injury Statement in Your Own Words

Job Analysis/Physical Demands

Medical Waiver and Consent (106)

Notice of Designated Physician (113)

Request for Payment/Reimbursement (114)

Wage Certification (AWW-1)

Workers’ Compensation Temporary Prescription ID Card

Workers’ Compensation Treatment Plan

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Louisiana

General Forms

Authorization to Disclose Health Information

Certificate of Compliance (WC-1025)

First Report of Injury (LDOL-WC-1007)

Injury Statement in Your Own Words

Job Analysis/Physical Demands

Louisiana Workers’ Compensation Second Injury Board Post-Hire/Conditional Job Offer Knowledge Questionnaire

Notice of Payment, Modification, Suspension, Termination or Controversion of Compensation or Medical Benefits (LDOL-WC-1002)

Notice to Injured Workers: Choose Your Own Doctor (WC-1121)

Stop Payment Form (LDOL-WC-1003)

Travel Expense Reimbursement

Workers’ Compensation Temporary Prescription ID Card

Access Louisiana Claims ID cards

Mississippi

Authorization to Disclose Health Information

First Report of Injury (IAIBC-IA-1)

Injury Statement in Your Own Words

Job Analysis/Physical Demands

Notice of Final Payment (B31)

Notice of Physician Choice

Travel Expense Reimbursement

Workers’ Compensation Temporary Prescription ID Card

Access Mississippi Claims ID cards

North Carolina

Authorization to Disclose Health Information

Employer’s First Report of Employee Injury (Form 19)

Injury Statement in Your Own Words

Itemized Statement of Charges for Drugs (Form 25P)

Itemized Statement of Charges for Travel (Form 25T)

Job Analysis/Physical Demands

Notice of Accident and Claim (Form 18)

Statement of Days Worked and Earnings (Form 22)

Workers’ Compensation Temporary Prescription ID Card

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Oklahoma

Authorization to Disclose Health Information

Employer’s First Notice of Injury (CC-Form 2)

Injury Statement in Your Own Words

Job Analysis/Physical Demands

Oklahoma Workers’ Compensation Notice and Instruction to Employers and Employees (CC-Form 1A)

Travel Expense Reimbursement

CWMP Grievance form

CWMP Dispute form

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South Carolina

Authorization to Disclose Health Information

First Report of Injury (Form 12-A)

Injury Statement in Your Own Words

Job Analysis/Physical Demands

Statement of Earnings (Form 20)

Travel Expense Reimbursement

Workers’ Compensation Temporary Prescription ID Card

Workers’ Compensation Treatment Plan

Access South Carolina Claims ID cards

Tennessee

Employee’s Choice of Physician (C-42)

Authorization to Disclose Health Information

First Report of Injury (C-20)

Job Analysis/Physical Demands

Injury Statement in Your Own Words

Medical Waiver and Consent (C-31)

Travel Expense Reimbursement

Wage Statement (C-41)

Workers’ Compensation Temporary Prescription ID Card

Workers’ Compensation Treatment Plan

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Texas

Authorization to Disclose Health Information

Claim for Workers’ Compensation Death Benefits (DWC042)

Employers Wage Statement (DWC Form-003)

First Report of Injury (DWC Form-001)

Injury Statement In Your Own Words

Job Analysis/Physical Demands

Notice of Injured Employee Rights and Responsibilities

Request for Travel Cost Reimbursement (DWC048)

Request for Travel Cost Reimbursement (DWC048) Spanish

Return to Work Reimbursement Program Information

Return to Work Reimbursement Program for Employers (DWC008)

Supplemental Report of Injury (DWC Form-006)

Workers’ Compensation Temporary Prescription ID Card

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Virginia

First Report of Injury

Authorization to Disclose Health Information

Injury Statement in Your Own Words

Job Analysis/Physical Demands

Virginia Transportation/Travel Expense Form

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