DME
Fill out all online forms below and fax to 818-654-0155 or 888-477-4880 or email all completed forms to [email protected]
Initial Report (Doctor's First Report) - http://www.dir.ca.gov/dwc/forms/5021.pdf
- Use Internet Explorer to download forms (you cannot download the forms in Google Chrome and there may be issues with other browser software).
- Must use Adobe Acrobat Professional in order to save downloaded forms. You may save blank forms and filled forms that can be edited later. You should save a blank copy of each form and then can modify each form for each patient using the "save as" function to make a new .pdf document for each new form for each patient. If you are unable to save the forms please check if your browser or Acrobat software needs updating.
RFA (Request for Authorization) -
http://www.dir.ca.gov/dwc/DWCPropRegs/IMR/IMRFormR...
PR-2 (Progress Report) -
http://www.dir.ca.gov/dwc/pr-2.pdf
To fax: Complete all forms below before faxing in order to be accepted.
Fax all completed forms to (818) 654-0155 or (888) 477-4880.
Patient Demographic Printable Form
Medical Necessity Printable Form
Doctor's First Report of Occupational Injury or Illness Printable Form