Texas Mutual Insurance Company - Providers of Workers' Comp Insurance

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 PDF
DWC-66, Statement for Pharmacy Services   PDF
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 PDF
DWC-73, Work Status Report   PDF
LHL-009, Request for Review by an Independent Review Organization (English)   PDF
LHL-009, Request for Review by an Independent Review Organization (Spanish)   PDF

Note

DWC's current billing instructions for health care providers and hospitals are available online.

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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.


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