Below are common forms and resources providers may need when treating injured workers.

Provider Registration
Payee Registration & Substitute W-9

Treating an Injured Worker
Capability Assessment (C3) form
Documentation Guidelines
First Report of Injury (FROI) form
The Role of Medical Case Manager

Authorization
Durable Medical Equipment Guide
Post Injection Pain Response form
Utilization Review Guide
Utilization Review (UR-C) form

Billing/Appeals
Advanced Beneficiary Notice (ABN) form
Remittance Advice Reason Codes
Fee Schedules
Medical Service Dispute Resolution Request (M2) form
Provider Request for Adjustment (M6) form

Chiropractic Information
Chiropractic Final Progress Report (C25) form
Quick Tips for Chiropractors
Utilization Review – Chiro (UR-Chiro) form

Forms required for Palliative Care requests:
Dallas Pain Questionnaire form
Oswestry Questionnaire form
Ransford Pain Drawing form
Visual Analog Pain Scale form
Neck Disability Index form (if applicable)

Provider News
Provider news and updates

Therapy Information
Electro Medical Device Request (M5) form
Independent Exercise; Work Hardening/Conditioning Requests (C59a) form
Quick Tips for Physical and Occupational Therapists
Utilization Review Guide
Utilization Review (UR-C) form