QME Continuing Education Home Study Program
Qualified Medical Evaluator Forms
Utilization Review Complaint FormsUtilization Review Forms - DWC UR Form 1
Pre-designation of Personal Physician / Change of Physician Forms
Notice of Pre-designation of Personal Physician Form - DWC Form 9783
Notice of Personal Chiropractor or Acupuncturist - DWC Form 9783.1
Primary Treating Physician Forms
Primary Treating Physician Permanent and Stationary Report (2005 rating schedule) - DWC Form PR-4
Primary Treating Physician Permanent and Stationary Report (1997 rating schedule) - DWC Form PR-3
Primary Treating Physician's Progress Report - DWC Form PR-2
Treating Physician's Determination of Medical Issues - IMC Form 81556
Spinal Surgery Second Opinion Forms
Application for spinal surgery second opinion physician list - SSSO Form 232
Objection to treating physician's recommendation for spinal surgery - SSSO Form 232
Medical Provider Network (MPN) Forms
Cover page for medical provider network application - DWC form 9767.4
Independent medical review application (for injured workers who need to get an independent medical review) - DWC form 9768.10
Notice of medical provider network plan modification Labor Code 9767.8 - DWC form 9767.8
Physician contract application (for doctors who want to become independent medical reviewers) - DWC form 9768.5
Sample initial written employee notification re: Medical provider network