Forms
Click on the links below to open a copy of the most commonly used Texas Department of Insurance, Division of Workers' Compensation (DWC) forms. If you have any problem printing the forms, check our tips for downloading and printing forms.
| Form | Format | |
| DWC-60, Medical Dispute Resolution Request / Response | ||
| DWC-66, Statement for Pharmacy Services | ||
| DWC-67, Instructions for Completing the CMS - 1500 | See note below | |
| DWC-68, Instructions for Completing the UB - 04 | See note below | |
| DWC-69, Report of Medical Evaluation | ||
| DWC-73, Work Status Report | ||
| LHL-009, Request for Review by an Independent Review Organization (English) | ||
| LHL-009, Request for Review by an Independent Review Organization (Spanish) | ||
Note
DWC's current billing instructions for health care providers and hospitals are available online beginning on Page 7 of the Clean Claim Electronic Medical Billing and Payment Workers' Compensation Companion Guides.
More forms on the Web
For more forms related to workers’ compensation insurance or general health care issues, visit the appropriate agency’s website, listed below.