Tools for authorized representatives
Filing a claim - Applicable forms
- Injured Worker Authorized Representative (R-2)
- Employer Authorized Representative (R-1)
- Authorization to Release Medical Information (C-101)
- Autorización para divulger información médica (C-101-ES)
Normally for workers' compensation claims, injured workers use the C-101 to ask providers to release medical information. However, sometimes providers, due to HIPPA concerns, will require a provider's proprietary medical release form. To address this potential issue, we're making Medicaid's medical release form available for download.
Note: Before you begin, download the instructions.
- Consent to Release Information (C-72)
- ACT Enrollment and Direct Deposit Authorization (A-12)
- EBT - Electronic Benefit Card Enrollment Application (A-21)
- Direct Deposit ACT Bank Change (A-35)
- First Report of an Injury, Occupational Disease or Death (FROI)
- Informe inicial de lesión, enfermedad ocupacional o fallecimiento (FROI-ES)
- Presumption of Causation for Firefighter Cancer (C-265)
Temporary total/Salary continuation - Applicable forms
- Request for Temporary Total Compensation (C-84)
- Petición de compensación total temporal (C-84-ES)
- Physician's Report of Work Ability (MEDCO-14)
Wage loss - applicable forms
- Application for Wage Loss Compensation (C-140)
- Wage Loss Statement for Job Search (C-141)
- Employer Report of Employee Earnings for Wage Loss Compensation (C-142)
Scheduled loss - applicable forms
Percentage of permanent partial - Applicable forms
- Application for Determination or Increase of Permanent Partial Disability (C-92)
- Objection to Tentative Order Awarding Permanent Partial Disability Compensation (C-167-T)
- Agreement as to Compensation for PPD (IC-CG1)
Permanent total disability (PTD)/DWRF - Applicable forms
- Application for Compensation for Permanent Total Disability (IC-2)
- PTD rate calculation worksheet - Instructions
- PTD rate calculation worksheet
Lump sum settlement - Applicable forms
- Settlement Agreement and Application for Approval of Settlement Agreement for state-fund claims only (C-240)
- Medical History and Disclosure (C-242)
- PTD-Death Settlement Acknowledgement and Waiver Full and Final Settlement (C-243)
- Indemnity Only Settlement Acknowledgement and Waiver (C-245)
- Notice of Intent to Settle (C-512)
Lump sum advancement - Applicable forms
Wages - Applicable forms
- Injured Worker Earnings Statement (WAGES-IW)
- Declaración de los ingresos del trabajador lesionado (WAGES-IW-ES)
- Employer Report of Employee Earnings (WAGES-EMP)
- Informe del empleador de ingresos del empleado (WAGES-EMP-ES)
Travel reimbursement - Applicable forms
- Completing the Injured Worker Statement for Reimbursement of Travel Expense
- Injured Worker Reimbursement Rates for Travel Expense
Other - Applicable forms
- ADR Appeal to the MCO Medical Treatment/Service Decision (C-11)
- Notice to Change Physician of Record (C-23)
- Injured Worker's Change of Address Notification (C-77)
- Motion (C-86)
- Moción (C-86-ES)
- Waiver of Appeal (C-108)
- Authorization to Receive Workers' Compensation Check (C-230)
- Autorización para recibir Cheques de compensación por accidentes en el trabajo (C-230-ES)
- Affidavit for Attorney Fees
- Application for Representative Identification Number (R-4)
- Net present value factors chart 2021 - Effective April 1, 2021
Resources
- Compensation rates
- Pension calendar
- Absorption Rates for Overpayment Chart
- Customer Service Office Triage Assignment and Contact Information
- Provider Signature on Medical Evidence
- Request for Changes Related to BWC Representative ID Number (C-267)