:: Forms

“Our AdvoCare representative was very informative, and made the reporting experience easy.”

Angela M. DeSantis
President/Owner
The A.G. DeSantis Co., Inc.

Here we have collected essential BWC forms, brochures, fact sheets, and other key documents for employers, injured workers, and providers.

Employers
 
 TitleCategorySize
CD-130 - Getting Back to WorkBrochures142.16 KB
FB - Fraud BrochureBrochures643.75 KB
Claim ReactivationFact Sheets37.24 KB
FS15K - BWC's $15,000 Medical-Only ProgramFact Sheets39.61 KB
FSHR - Handicap ReimbursementFact Sheets31.62 KB
FSMM - Maximum Medical ImprovementFact Sheets35.53 KB
FSRAW - Remain at WorkFact Sheets40.79 KB
FSSC - BWC's Salary Continuation PolicyFact Sheets38.67 KB
FSSH - Safety & Hygiene ServicesFact Sheets40.45 KB
FSTN - Service offices Contact InformationFact Sheets33.48 KB
FSWCA - Workers' Compensation BenefitsFact Sheets36.16 KB
SubrogationFact Sheets37.83 KB
Workers' Compensation and HIPAAFact Sheets45.12 KB
AdvoCare ID Card (Sample)Forms64.15 KB
AdvoCare Injury Reporting PacketForms290.10 KB
AdvoCare MCO Selection FormForms46.46 KB
C-11 - ADR Appeal to the MCO Medical Treatment/Service DecisionForms68.24 KB
C-30 - Request for Medical InformationForms41.96 KB
C-55 - Salary Continuation AgreementForms42.28 KB
C-94-A - Wage StatementForms135.50 KB
C-101 - Authorization to Release Medical InformationForms46.46 KB
C-108 - Waiver of AppealForms113.40 KB
FROI - First Report of an Injury, Occupational Disease or DeathForms107.52 KB
FROI-ES - First Report of an Injury, Occupational Disease or Death (En Español)Forms107.84 KB
Subrogation Referral FormForms11.61 KB
U-117 - Notification of Policy UpdateForms60.13 KB
DG10 - Safety Leader's Discussion Guide for 2010Manuals625.86 KB
DS23 - Services CatalogManuals496.76 KB
BASICS - BWC BasicsOther603.48 KB
Injured Workers
Providers
 
 TitleCategorySize
CD-106 - BWC Medical GuideBrochures710.75 KB
CD-130 - Getting Back to WorkBrochures142.16 KB
Claim ReactivationFact Sheets37.24 KB
Forms and Health Information Requested Under HIPAAFact Sheets33.37 KB
FSMM - Maximum Medical ImprovementFact Sheets35.53 KB
FSRAW - Remain at WorkFact Sheets40.79 KB
SubrogationFact Sheets37.83 KB
Workers' compensation and HIPAAFact Sheets45.12 KB
Workers' Compensation Claims Management Guidelines for Exposure to Blood and Other Bodily Fluids under SB 223Fact Sheets45.29 KB
C-9 - Physician's Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational DiseaseForms90.77 KB
C-9-A - Request for Additional Medical Documentation for C-9Forms45.17 KB
C-11 - ADR Appeal to the MCO Medical Treatment/Service DecisionForms68.24 KB
C-19 - Service InvoiceForms42.96 KB
C-84 - Request for Temporary Total CompensationForms173.08 KB
C-84-ES - Request for Temporary Total Compensation (En Español)Forms159.58 KB
COVER - Medical Documentation Fax Cover SheetForms47.10 KB
FROI - First Report of an Injury, Occupational Disease or DeathForms107.52 KB
FROI-ES - First Report of an Injury, Occupational Disease or Death (En Español)Forms107.84 KB
MEDCO-12 - Request to Change Provider InformationForms58.17 KB
MEDCO-13 - Application for Provider Enrollment and CertificationForms83.52 KB
MEDCO-13A - Application for Provider Enrollment Non-CertificationForms64.45 KB
MEDCO-14 - Physician's Report of Work AbilityForms68.43 KB
MEDCO-31 - Request for Prior Authorization of Medication FormForms39.66 KB
MEDCO-32 - Request for Prior Authorization of NON-PREFERRED Medication FormForms44.65 KB
ICD 9-I - ICD-9 Invalid CodesOther164.48 KB
ICD9G - ICD-9 GroupsOther260.38 KB