Work comp: Forms
About the forms
The forms provided below are fillable PDFs that can be viewed or printed using the free Adobe Acrobat Reader software. However, that software does not allow users the option of saving data that is typed into the filled-in PDF; to have the option to save input information, visit www.adobe.com for more information about Adobe Acrobat software.
The fill-in PDF will automatically enter the slashes for dates, the parentheses and hyphen for phone numbers and the hyphens for Social Security numbers.
Notice of Aug. 31, 2020, effective date of required electronic filing of non-EDI workers' compensation reports or documents by web form, upload or XML attachment
Online submission options
Attorney Request for Certification of Dispute, Medical Request, Medical Response, Rehabilitation Request, Rehabilitation Response
A feature of this online filing tool allows users to save filed dispute documents. It also requires users to login to the system in a new way – learn more. Because of the feature, users can now save incomplete files they are still working on, save completed files and review dispute documents that have already been filed.
– User information about submission of online Medical Request and Rehabilitation Request forms.
A to Z – required workers' compensation forms (required by statute, rule)
The Spanish versions of forms are to be used for communication purposes only; they should not be filed with the department.
Workers' Compensation Report of Benefits Paid (updated annually)
Optional forms (suggested format, not required by statute, rule)
|Form name||Version date||Notes|
|Attorney Request for Certification of Dispute (CA0022)||June 2013||Renamed, revised|
|Authorization for File Review or Release of Copies of Workers' Compensation Claim File (FE0055)||June 2011|
|Benefit Addendum (BA01) – more information||July 2010|
|Disclosure of Affiliations and/or Relationships|
|Functional Capacity Evaluation||October 2009||New form|
|Model patient/provider contract for long-term treatment with opioid medication||May 2016|
|Motion to Intervene (MO0001)||August 2018||Format changes|
|Notice of File Closing (NF01) – more information||May 2008||New mailing address|
|Notice of Penalty Payment (NO0015)||October 2014||Format changes|
|Occupational On-site Analysis||October 2009||New form|
|Penalty Request for Failure to Pay or Deny Rehabilitation Invoice||June 2019||Legislative changes|
|Rehabilitation Provider Complaint||October 2012||New form|
|Stipulation of Intervention (LE0032)||June 2018||Legislative changes|
Rehabilitation provider forms
Qualified rehabilitation consultant (QRC) internship completion checklist
|Form name||Version date||Notes|
|R-20 Qualified Rehabilitation Consultant Intern Application||July 2015||Law change|
|R-22 Rehabilitation Vendor Application||July 2015||Law change|
|R-24 Qualified Rehabilitation Consultant Firm Application||July 2015||Law change|
|R-25 Qualified Rehabilitation Consultant Application||July 2015||Law change|
Rehabilitation plan service codes and categories
For more information about workers' compensation forms, contact the Workers' Compensation Division Help Desk at firstname.lastname@example.org, 651-284-5005 (press 3) or 800-342-5354 (press 3).