TADSIG - Claim Forms
Preauthorization Request Form: Per the Worker's Compensation Rules, certain medical procedures and/or treatments must be pre-authorized by the treated Physician. This form should be faxed to UniMed Services to initiate the preauthorization process.
REQUIRED FORMS FOR EMPLOYERS:
Texas Employer’s First Report of Injury Form (DWC-1): This form should be completed in its entirety and submitted to us for any injury requiring medical care. If the employee does not need treatment, you can submit the “Supervisors Incident Report” listed under OPTIONAL FORMS.
Employer’s Report for Reimbursement of Voluntary Payment (DWC-2): This form enables an employer who voluntarily begins payment to an injured worker to recoup from the insurance carrier once a determination of compensability has been made.
Notice to Employees Concerning Workers’ Compensation in Texas (NOTICE 6): This form is required to be posted in a prominent place to advise your employees that you have workers compensation coverage and to advise your employees of the DWC’s toll free number to obtain information about their workers’ compensation rights.
Employer’s Wage Statement (DWC-3): Please submit this form within 30 days of the employee’s eighth day of disability or upon request by your claims adjuster.
Supplemental Report of Injury (DWC-6): This form must be filed in the following situations within the timeframes indicated:
- 3 days after the injured worker begins to lose time from work as a result of the injury, if lost time did not occur immediately following the injury;
- 3 days after the injured worker returns to work;
- 3 days, when the injured worker returned to work, then later has additional day(s) of lost time as a result of the injury;
- 10 days after the end of each pay period in which the injured worker has a change in earnings as a result of the injury;
- 10 days after the injured worker resigns or is terminated.