The DWC 1 form, officially known as the Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility, serves as a crucial document for workers in California who have suffered a job-related injury or illness, including those resulting from workplace crimes, signaling their intent to claim workers' compensation benefits. This form initiates the process by requiring the injured or ill employee to provide detailed information about their condition and the circumstances leading to it, which is then used by employers and claims administrators to assess eligibility for compensation benefits. To ensure that workers understand their rights and the steps necessary for filing a claim, they are advised to meticulously read all provided information and retain copies for their records. Start your claim by clicking the button below to fill out your DWC 1 form.
In the realm of workers' compensation, the DWC 1 form serves as a critical starting point for employees seeking benefits due to job-related injuries or illnesses. Complying with several sections of the Labor Code, this form, also known as the Workers' Compensation Claim Form & Notice of Potential Eligibility, sets the stage for the claims process. Upon experiencing a work-related physical or mental injury, including ones resulting from workplace crimes, employees are directed to use this form to formally file a claim with their employer. The importance of meticulously completing this document and adhering to the specified protocols can't be overstressed, as it not only initiates the process but also influences the timeliness and receipt of entitled workers’ compensation benefits. Employers, upon receiving the filled form, are obliged to respond within a stipulated period, indicating acceptance of the claim or the need for further investigation. The form further delves into procedures surrounding medical care, illustrating how claims administrators take charge of medical expenses ensuring that the injured party receives necessary and reasonable treatment without financial burden. Additionally, it touches on the rights employees have concerning medical treatment, changing physicians within certain networks, and the disclosure of medical records. A comprehensive understanding of these components is crucial for navigating the intricacies of workers’ compensation and safeguarding one's rights and benefits effectively.
§10139. Workers’ Compensation Claim Form (DWC 1) and Notice of Potential Eligibility.
Note: Authority cited: Sections 133 5307.3 and 5401, Labor Code. Reference: Sections 132(a), 139.48, 139.6, 4600, 4600.3, 4601, 4604.5, 4616, 4650, 4656, 4658.5, 4658.6, 4700, 4701, 4702, 4703, 5400, 5401, 5401.7 and 5402, Labor Code.
Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility
Formulario de Reclamo de Compensación de Trabajadores (DWC 1) y Notificación de Posible Elegibilidad
If you are injured or become ill, either physically or mentally, because of your job, including injuries resulting from a workplace crime, you may be entitled to workers’ compensation benefits. Use the attached form to file a workers’ compensation claim with your employer. You should read all of the information below. Keep this sheet and all other papers for your records. You may be eligible for some or all of the benefits listed depending on the nature of your claim. If you file a claim, the claims administrator, who is responsible for handling your claim, must notify you within 14 days whether your claim is accepted or whether additional investigation is needed.
To file a claim, complete the “Employee” section of the form, keep one copy and give the rest to your employer. Do this right away to avoid problems with your claim. In some cases, benefits will not start until you inform your employer about your injury by filing a claim form. Describe your injury completely. Include every part of your body affected by the injury. If you mail the form to your employer, use first-class or certified mail. If you buy a return receipt, you will be able to prove that the claim form was mailed and when it was delivered. Within one working day after you file the claim form, your employer must complete the “Employer” section, give you a dated copy, keep one copy, and send one to the claims administrator.
Medical Care: Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness. Medical benefits are subject to approval and may include treatment by a doctor, hospital services, physical therapy, lab tests, x-rays, medicines, equipment and travel costs. Your claims administrator will pay the costs of approved medical services directly so you should never see a bill. There are limits on chiropractic, physical therapy, and other occupational therapy visits.
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness.
If you previously designated your personal physician or a medical group, you may see your personal physician or the medical group after you are injured.
If your employer is using a medical provider network (MPN) or Health Care Organization (HCO), in most cases, you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group. An MPN is a group of health care providers who provide treatment to workers injured on the job. You should receive information from your employer if you are covered by an HCO or a MPN. Contact your employer for more information.
If your employer is not using an MPN or HCO, in most cases, the claims administrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group.
If your employer has not put up a poster describing your rights to workers’ compensation, you may be able to be treated by your personal physician right after you are injured.
Within one working day after you file a claim form, your employer or the claims administrator must authorize up to $10,000 in treatment for your injury, consistent with the applicable treating guidelines until the claim is accepted or rejected. If the employer or claims administrator does not authorize treatment right away, talk to your supervisor, someone else in management, or the claims administrator. Ask for treatment to be authorized right now, while waiting for a decision on your claim. If the employer or claims administrator will not authorize treatment, use your own health insurance to get medical care. Your health insurer will seek reimbursement from the claims administrator. If you do not have health insurance, there are doctors, clinics or hospitals that will treat you without immediate payment. They will seek reimbursement from the claims administrator.
Switching to a Different Doctor as Your PTP:
If you are being treated in a Medical Provider Network (MPN), you may switch to other doctors within the MPN after the first visit.
If you are being treated in a Health Care Organization (HCO), you may switch at least one time to another doctor within the HCO. You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer- provided health insurance).
If you are not being treated in an MPN or HCO and did not predesignate, you may switch to a new doctor one time during the first 30 days after your injury is reported to your employer. Contact the claims administrator to switch doctors. After 30 days, you may switch to a doctor of your choice if
Rev. 1/1/2016
Si Ud. se lesiona o se enferma, ya sea físicamente o mentalmente, debido a su trabajo, incluyendo lesiones que resulten de un crimen en el lugar de trabajo, es posible que Ud. tenga derecho a beneficios de compensación de trabajadores. Utilice el formulario adjunto para presentar un reclamo de compensación de trabajadores con su empleador. Ud. debe leer toda la información a continuación. Guarde esta hoja y todos los demás documentos para sus archivos. Es posible que usted reúna los requisitos para todos los beneficios, o parte de éstos, que se enumeran dependiendo de la índole de su reclamo. Si usted presenta un reclamo, l administrador de reclamos, quien es responsable por el manejo de su reclamo, debe notificarle dentro de 14 días si se acepta su reclamo o si se necesita investigación adicional.
Para presentar un reclamo, llene la sección del formulario designada para el “Empleado,” guarde una copia, y déle el resto a su empleador. Haga esto de inmediato para evitar problemas con su reclamo. En algunos casos, los beneficios no se iniciarán hasta que usted le informe a su empleador acerca de su lesión mediante la presentación de un formulario de reclamo. Describa su lesión por completo. Incluya cada parte de su cuerpo afectada por la lesión. Si usted le envía por correo el formulario a su empleador, utilice primera clase o correo certificado. Si usted compra un acuse de recibo, usted podrá demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado. Dentro de un día laboral después de presentar el formulario de reclamo, su empleador debe completar la sección designada para el “Empleador,” le dará a Ud. una copia fechada, guardará una copia, y enviará una al administrador de reclamos.
Atención Médica: Su administrador de reclamos pagará por toda la atención médica razonable y necesaria para su lesión o enfermedad relacionada con el trabajo. Los beneficios médicos están sujetos a la aprobación y pueden incluir tratamiento por parte de un médico, los servicios de hospital, la terapia física, los análisis de laboratorio, las medicinas, equipos y gastos de viaje. Su administrador de reclamos pagará directamente los costos de los servicios médicos aprobados de manera que usted nunca verá una factura. Hay límites en terapia quiropráctica, física y otras visitas de terapia ocupacional.
El Médico Primario que le Atiende (Primary Treating Physician- PTP) es el médico con la responsabilidad total para tratar su lesión o enfermedad.
Si usted designó previamente a su médico personal o a un grupo médico, usted podrá ver a su médico personal o grupo médico después de lesionarse.
Si su empleador está utilizando una red de proveedores médicos (Medical Provider Network- MPN) o una Organización de Cuidado Médico (Health Care Organization- HCO), en la mayoría de los casos, usted será tratado en la MPN o HCO a menos que usted hizo una designación previa de su médico personal o grupo médico. Una MPN es un grupo de proveedores de asistencia médica quien da tratamiento a los trabajadores lesionados en el trabajo. Usted debe recibir información de su empleador si su tratamiento es cubierto por una HCO o una MPN. Hable con su empleador para más información.
Si su empleador no está utilizando una MPN o HCO, en la mayoría de los casos, el administrador de reclamos puede elegir el médico que lo atiende primero a menos de que usted hizo una designación previa de su médico personal o grupo médico.
Si su empleador no ha colocado un cartel describiendo sus derechos para la compensación de trabajadores, Ud. puede ser tratado por su médico personal inmediatamente después de lesionarse.
Dentro de un día laboral después de que Ud. Presente un formulario de reclamo, su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesión, de acuerdo con las pautas de tratamiento aplicables, hasta que el reclamo sea aceptado o rechazado. Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato, hable con su supervisor, alguien más en la gerencia, o con el administrador de reclamos. Pida que el tratamiento sea autorizado ya mismo, mientras espera una decisión sobre su reclamo. Si el empleador o administrador de reclamos no autoriza el tratamiento, utilice su propio seguro médico para recibir atención médica. Su compañía de seguro médico buscará reembolso del administrador de reclamos. Si usted no tiene seguro médico, hay médicos, clínicas u hospitales que lo tratarán sin pago inmediato. Ellos buscarán reembolso del administrador de reclamos.
Cambiando a otro Médico Primario o PTP:
Si usted está recibiendo tratamiento en una Red de Proveedores Médicos Page 1 of 3
your employer or the claims administrator has not created or selected an MPN.
Disclosure of Medical Records: After you make a claim for workers' compensation benefits, your medical records will not have the same level of privacy that you usually expect. If you don’t agree to voluntarily release medical records, a workers’ compensation judge may decide what records will be released. If you request privacy, the judge may "seal" (keep private) certain medical records.
Problems with Medical Care and Medical Reports: At some point during your claim, you might disagree with your PTP about what treatment is necessary. If this happens, you can switch to other doctors as described above. If you cannot reach agreement with another doctor, the steps to take depend on whether you are receiving care in an MPN, HCO, or neither. For more information, see “Learn More About Workers’ Compensation,” below.
If the claims administrator denies treatment recommended by your PTP, you may request independent medical review (IMR) using the request form included with the claims administrator’s written decision to deny treatment. The IMR process is similar to the group health IMR process, and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given. Your attorney or your physician may assist you in the IMR process. IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician.
If you disagree with your PTP on matters other than treatment, such as the cause of your injury or how severe the injury is, you can switch to other doctors as described above. If you cannot reach agreement with another doctor, notify the claims administrator in writing as soon as possible. In some cases, you risk losing the right to challenge your PTP’s opinion unless you do this promptly. If you do not have an attorney, the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute. If you have an attorney, the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME). If the claims administrator disagrees with your PTP on matters other than treatment, the claims administrator can require you to be seen by a QME or AME.
Payment for Temporary Disability (Lost Wages): If you can't work while you are recovering from a job injury or illness, you may receive temporary disability payments for a limited period. These payments may change or stop when your doctor says you are able to return to work. These benefits are tax-free. Temporary disability payments are two-thirds of your average weekly pay, within minimums and maximums set by state law. Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days.
Stay at Work or Return to Work: Being injured does not mean you must stop working. If you can continue working, you should. If not, it is important to go back to work with your current employer as soon as you are medically able. Studies show that the longer you are off work, the harder it is to get back to your original job and wages. While you are recovering, your PTP, your employer (supervisors or others in management), the claims administrator, and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do. Actively communicate with your PTP, your employer, and the claims administrator about the work you did before you were injured, your medical condition and the kinds of work you can do now, and the kinds of work that your employer could make available to you.
Payment for Permanent Disability: If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do, you may receive additional payments. The amount will depend on the type of injury, extent of impairment, your age, occupation, date of injury, and your wages before you were injured.
Supplemental Job Displacement Benefit (SJDB): If you were injured on or after 1/1/04, and your injury results in a permanent disability and your employer does not offer regular, modified, or alternative work, you may qualify for a nontransferable voucher payable for retraining and/or skill enhancement. If you qualify, the claims administrator will pay the costs up to the maximum set by state law.
Death Benefits: If the injury or illness causes death, payments may be made to a
(Medical Provider Network- MPN), usted puede cambiar a otros médicos dentro de la MPN después de la primera visita.
Si usted está recibiendo tratamiento en un Organización de Cuidado Médico (Healthcare Organization- HCO), es posible cambiar al menos una vez a otro médico dentro de la HCO. Usted puede cambiar a un médico fuera de la HCO 90 o 180 días después de que su lesión es reportada a su empleador (dependiendo de si usted está cubierto por un seguro médico proporcionado por su empleador).
Si usted no está recibiendo tratamiento en una MPN o HCO y no hizo una designación previa, usted puede cambiar a un nuevo médico una vez durante los primeros 30 días después de que su lesión es reportada a su empleador. Póngase en contacto con el administrador de reclamos para cambiar de médico. Después de 30 días, puede cambiar a un médico de su elección si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN.
Divulgación de Expedientes Médicos: Después de que Ud. presente un reclamo para beneficios de compensación de trabajadores, sus expedientes médicos no tendrán el mismo nivel de privacidad que usted normalmente espera. Si Ud. no está de acuerdo en divulgar voluntariamente los expedientes médicos, un juez de compensación de trabajadores posiblemente decida qué expedientes serán revelados. Si usted solicita privacidad, es posible que el juez “selle” (mantenga privados) ciertos expedientes médicos.
Problemas con la Atención Médica y los Informes Médicos: En algún momento durante su reclamo, podría estar en desacuerdo con su PTP sobre qué tratamiento es necesario. Si esto sucede, usted puede cambiar a otros médicos como se describe anteriormente. Si no puede llegar a un acuerdo con otro médico, los pasos a seguir dependen de si usted está recibiendo atención en una MPN, HCO o ninguna de las dos. Para más información, consulte la sección “Aprenda Más Sobre la Compensación de Trabajadores,” a continuación.
Si el administrador de reclamos niega el tratamiento recomendado por su PTP, puede solicitar una revisión médica independiente (Independent Medical Review- IMR), utilizando el formulario de solicitud que se incluye con la decisión por escrito del administrador de reclamos negando el tratamiento. El proceso de la IMR es parecido al proceso de la IMR de un seguro médico colectivo, y tarda aproximadamente 40 (o menos) días para llegar a una determinación de manera que se pueda dar un tratamiento apropiado. Su abogado o su médico le pueden ayudar en el proceso de la IMR. La IMR no está disponible para resolver disputas sobre cuestiones aparte de la necesidad médica de un tratamiento particular solicitado por su médico.
Si no está de acuerdo con su PTP en cuestiones aparte del tratamiento, como la causa de su lesión o la gravedad de la lesión, usted puede cambiar a otros médicos como se describe anteriormente. Si no puede llegar a un acuerdo con otro médico, notifique al administrador de reclamos por escrito tan pronto como sea posible. En algunos casos, usted arriesg perder el derecho a objetar a la opinión de su PTP a menos que hace esto de inmediato. Si usted no tiene un abogado, el administrador de reclamos debe enviarle instrucciones para ser evaluado por un médico llamado un evaluador médico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa. Si usted tiene un abogado, el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un médico llamado un evaluador médico acordado (Agreed Medical Evaluator- AME). Si el administrador de reclamos no está de acuerdo con su PTP sobre asuntos aparte del tratamiento, el administrador de reclamos puede exigirle que sea atendido por un QME o AME.
Pago por Incapacidad Temporal (Sueldos Perdidos): Si Ud. no puede trabajar, mientras se está recuperando de una lesión o enfermedad relacionada con el trabajo, Ud. puede recibir pagos por incapacidad temporal por un periodo limitado. Estos pagos pueden cambiar o parar cuando su médico diga que Ud. está en condiciones de regresar a trabajar. Estos beneficios son libres de impuestos. Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio, con cantidades mínimas y máximas establecidas por las leyes estales. Los pagos no se hacen durante los primeros tres días en que Ud. no trabaje, a menos que Ud. sea hospitalizado una noche o no puede trabajar durante más de 14 días.
Permanezca en el Trabajo o Regreso al Trabajo: Estar lesionado no significa que usted debe dejar de trabajar. Si usted puede seguir trabajando, usted debe hacerlo. Si no es así, es importante regresar a trabajar con su empleador actual tan
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spouse and other relatives or household members who were financially dependent on the deceased worker.
It is illegal for your employer to punish or fire you for having a job injury or illness, for filing a claim, or testifying in another person's workers' compensation case (Labor Code 132a). If proven, you may receive lost wages, job reinstatement, increased benefits, and costs and expenses up to limits set by the state.
Resolving Problems or Disputes: You have the right to disagree with decisions affecting your claim. If you have a disagreement, contact your employer or claims administrator first to see if you can resolve it. If you are not receiving benefits, you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits. Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606, or go to their website at www.edd.ca.gov.
You Can Contact an Information & Assistance (I&A) Officer: State I&A officers answer questions, help injured workers, provide forms, and help resolve problems. Some I&A officers hold workshops for injured workers. To obtain important information about the workers’ compensation claims process and your rights and obligations, go to www.dwc.ca.gov or contact an I&A officer of the state Division of Workers’ Compensation. You can also hear recorded information and a list of local I&A offices by calling (800) 736-7401.
You can consult with an attorney. Most attorneys offer one free consultation. If you decide to hire an attorney, his or her fee will be taken out of some of your benefits. For names of workers' compensation attorneys, call the State Bar of California at (415) 538-2120 or go to their website at www. californiaspecialist.org.
Learn More About Workers’ Compensation: For more information about the workers’ compensation claims process, go to www.dwc.ca.gov. At the website, you can access a useful booklet, “Workers’ Compensation in California: A Guidebook for Injured Workers.” You can also contact an Information & Assistance Officer (above), or hear recorded information by calling 1-800-736- 7401.
pronto como usted pueda medicamente hacerlo. Los estudios demuestran que entre más tiempo esté fuera del trabajo, más difícil es regresar a su trabajo original y a sus salarios. Mientras se está recuperando, su PTP, su empleador (supervisores u otras personas en la gerencia), el administrador de reclamos, y su abogado (si tiene uno) trabajarán con usted para decidir cómo va a permanecer en el trabajo o regresar al trabajo y qué trabajo hará. Comuníquese de manera activa con su PTP, su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse, su condición médica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podría poner a su disposición.
Pago por Incapacidad Permanente: Si un médico dice que no se ha recuperado completamente de su lesión y siempre será limitado en el trabajo que puede hacer, es posible que Ud. reciba pagos adicionales. La cantidad dependerá de la clase de lesión, grado de deterioro, su edad, ocupación, fecha de la lesión y sus salarios antes de lesionarse.
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job
Displacement Benefit- SJDB): Si Ud. se lesionó en o después del 1/1/04, y su lesión resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular, modificado, o alternativo, usted podría cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento y/o mejorar su habilidad. Si Ud. cumple los requisios, el administrador de reclamos pagará los gastos hasta un máximo establecido por las leyes estatales.
Beneficios por Muerte: Si la lesión o enfermedad causa la muerte, es posible que los pagos se hagan a un cónyuge y otros parientes o a las personas que viven en el hogar que dependían económicamente del trabajador difunto.
Es ilegal que su empleador le castigue o despida por sufrir una lesión o enfermedad laboral, por presentar un reclamo o por testificar en el caso de compensación de trabajadores de otra persona. (Código Laboral, sección 132a.) De ser probado, usted puede recibir pagos por pérdida de sueldos, reposición del trabajo, aumento de beneficios y gastos hasta los límites establecidos por el estado.
Resolviendo problemas o disputas: Ud. tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo. Si Ud. tiene un desacuerdo, primero comuníquese con su empleador o administrador de reclamos para ver si usted puede resolverlo. Si usted no está recibiendo beneficios, es posible que Ud. pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI). Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333- 4606, o visite su página Web en www.edd.ca.gov.
Puede Contactar a un Oficial de Información y Asistencia (Information &
Assistance- I&A): Los Oficiales de Información y Asistencia (I&A) estatal contestan preguntas, ayudan a los trabajadores lesionados, proporcionan formularios y ayudan a resolver problemas. Algunos oficiales de I&A tienen talleres para trabajadores lesionados. Para obtener información importante sobre el proceso de la compensación de trabajadores y sus derechos y obligaciones, vaya a www.dwc.ca.gov o comuníquese con un oficial de información y asistencia de la División Estatal de Compensación de Trabajadores. También puede escuchar información grabada y una lista de las oficinas de I&A locales llamando al (800) 736-7401.
Ud. puede consultar con un abogado. La mayoría de los abogados ofrecen una consulta gratis. Si Ud. decide contratar a un abogado, los honorarios serán tomados de algunos de sus beneficios. Para obtener nombres de abogados de compensación de trabajadores, llame a la Asociación Estatal de Abogados de California (State Bar) al (415) 538-2120, o consulte su página Web en www.californiaspecialist.org.
Aprenda Más Sobre la Compensación de Trabajadores: Para obtener más información sobre el proceso de reclamos del programa de compensación de trabajadores, vaya a www.dwc.ca.gov. En la página Web, podrá acceder a un folleto útil, “Compensación del Trabajador de California: Una Guía para Trabajadores Lesionados.” También puede contactar a un oficial de Información
yAsistencia (arriba), o escuchar información grabada llamando al 1-800-736- 7401.
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.
State of California
Estado de California
Department of Industrial Relations
Departamento de Relaciones Industriales
DIVISION OF WORKERS’ COMPENSATION
DIVISION DE COMPENSACIÓN AL TRABAJADOR
WORKERS’ COMPENSATION CLAIM FORM (DWC 1)
PETITION DEL EMPLEADO PARA DE COMPENSACIÓN DEL
TRABAJADOR (DWC 1)
Employee: Complete the “Employee” section and give the form to your employer. Keep a copy and mark it “Employee’s Temporary Receipt” until you receive the signed and dated copy from your employer. You may call the Division of Workers’ Compensation and hear recorded information at (800) 736-7401. An explanation of workers' compensation benefits is included in the Notice of Potential Eligibility, which is the cover sheet of this form. Detach and save this notice for future reference.
You should also have received a pamphlet from your employer describing workers’ compensation benefits and the procedures to obtain them. You may receive written notices from your employer or its claims administrator about your claim. If your claims administrator offers to send you notices electronically, and you agree to receive these notices only by email, please provide your email address below and check the appropriate box. If you later decide you want to receive the notices by mail, you must inform your employer in writing.
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers’ compensation benefits or payments is guilty of a felony.
Empleado: Complete la sección “Empleado” y entregue la forma a su empleador. Quédese con la copia designada “Recibo Temporal del Empleado” hasta que Ud. reciba la copia firmada y fechada de su empleador. Ud. puede llamar a la Division de Compensación al Trabajador al (800) 736- 7401 para oir información gravada. Una explicación de los beneficios de compensación de trabajadores está incluido en la Notificación de Posible Elegibilidad, que es la hoja de portada de esta forma. Separe y guarde esta notificación como referencia para el futuro.
Ud. también debería haber recibido de su empleador un folleto describiendo los benficios de compensación al trabajador lesionado y los procedimientos para obtenerlos. Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo. Si su administrador de reclamos ofrece enviarle notificaciones electrónicamente, y usted acepta recibir estas notificaciones solo por correo electrónico, por favor proporcione su dirección de correo electrónico abajo y marque la caja apropiada. Si usted decide después que quiere recibir las notificaciones por correo, usted debe de informar a su empleador por escrito.
Toda aquella persona que a propósito haga o cause que se produzca cualquier declaración o representación material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensación a trabajadores lesionados es culpable de un crimen mayor “felonia”.
Employee—complete this section and see note above
Empleado—complete esta sección y note la notación arriba.
1.Name. Nombre. ___________________________________________________ Today’s Date. Fecha de Hoy. ____________________________________________
2.Home Address. Dirección Residencial. _____________________________________________________________________________________________________
3.
City. Ciudad. _______________________________________ State. Estado. _____________________ Zip. Código Postal. ______________________________
4.
Date of Injury. Fecha de la lesión (accidente). ________________________________ Time of Injury. Hora en que ocurrió. ____________a.m. ___________p.m.
5.Address and description of where injury happened. Dirección/lugar dónde occurió el accidente. _______________________________________________________
_______________________________________________________________________________________________________________________________________
6.Describe injury and part of body affected. Describa la lesión y parte del cuerpo afectada. ____________________________________________________________
7.Social Security Number. Número de Seguro Social del Empleado. _______________________________________________________________________________
8. Check if you agree to receive notices about your claim by email only. Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electrónico. Employee’s e-mail. _____________________________________ Correo electrónico del empleado. __________________________________________.
You will receive benefit notices by regular mail if you do not choose, or your claims administrator does not offer, an electronic service option. Usted recibirá notificaciones de beneficios por correo ordinario si usted no escoge, o su administrador de reclamos no le ofrece, una opción de servicio electrónico.
9. Signature of employee. Firma del empleado. ________________________________________________________________________________________________
Employer—complete this section and see note below. Empleador—complete esta sección y note la notación abajo.
10.Name of employer. Nombre del empleador. ________________________________________________________________________________________________
11.Address. Dirección. __________________________________________________________________________________________________________________
12.Date employer first knew of injury. Fecha en que el empleador supo por primera vez de la lesión o accidente. ___________________________________________
13.Date claim form was provided to employee. Fecha en que se le entregó al empleado la petición. ______________________________________________________
14.Date employer received claim form. Fecha en que el empleado devolvió la petición al empleador._____________________________________________________
15.Name and address of insurance carrier or adjusting agency. Nombre y dirección de la compañía de seguros o agencia adminstradora de seguros. _______________
16.Insurance Policy Number. El número de la póliza de Seguro.___________________________________________________________________________________
17.Signature of employer representative. Firma del representante del empleador. ____________________________________________________________________
18.Title. Título. _________________________________________ 19. Telephone. Teléfono. ___________________________________________________________
Employer: You are required to date this form and provide copies to your insurer or claims administrator and to the employee, dependent or representative who filed the claim within one working day of receipt of the form from the employee.
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador: Se requiere que Ud. feche esta forma y que provéa copias a su compañía de seguros, administrador de reclamos, o dependiente/representante de reclamos y al empleado que hayan presentado esta petición dentro del plazo de un día hábil desde el momento de haber sido recibida la forma del empleado.
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copy/Copia del Empleador Employee copy/Copia del Empleado Claims Administrator/Administrador de Reclamos Temporary Receipt/Recibo del Empleado
After an injury or illness at work, initiating a workers' compensation claim is a crucial step. The DWC 1 form is your gateway to this process, ensuring your right to potentially receive benefits is preserved and communicated properly to your employer. This form acts as the formal notification to your employer and starts the claims process. It's important to fill out this form accurately and promptly to avoid delays in your claim or the receipt of any benefits you're entitled to. Here is a straightforward guide to help you complete the DWC 1 form correctly.
Once the form is submitted to your employer, they have one working day to complete their section and provide copies to their insurance carrier or claims administrator and back to you. This prompt submission is vital as it triggers the start of the claim process, leading to a determination about your eligibility for benefits. Remember, accurately filling out and promptly submitting the DWC 1 form is the first step in safeguarding your rights and accessing the workers' compensation system for your recovery and well-being.
What is the DWC 1 form?
The DWC 1 form, known as the Workers' Compensation Claim Form & Notice of Potential Eligibility, is a critical document for workers in California who have been injured or have become ill due to their job. This form initiates the process for claiming workers' compensation benefits. By completing the "Employee" section and submitting it to their employer, an injured worker formally notifies the employer and the employer's insurance carrier of the injury or illness. It is the first step for an employee to obtain potential benefits such as medical treatment and compensation for lost wages.
How soon should the DWC 1 form be filed after an injury?
It is important to file the DWC 1 form as soon as possible after an injury or the diagnosis of a job-related illness. Filing this form right away helps to avoid delays in receiving benefits. Specifically, the injured worker should complete and submit this form to their employer immediately to facilitate quick action on their claim. California law requires employers to provide the form to an injured worker within one working day after learning about the injury or illness.
What happens after the DWC 1 form is submitted?
After an employee submits the DWC 1 form to their employer, the employer must fill out the "Employer" section of the form and return a dated copy to the employee within one working day. Then, the employer forwards the completed form to their workers' compensation insurance carrier. This triggers the claims process. The insurance carrier, also known as the claims administrator, must notify the employee within 14 days whether the claim is accepted, denied, or if additional investigation is necessary. In the meantime, the claims administrator is required to authorize up to $10,000 in medical treatment pending the decision on the claim.
Can I choose my own doctor for the treatment of my work-related injury or illness?
Yes, in certain circumstances. If you had previously designated a personal physician or a medical group in writing before the injury occurred, you might see them for your treatment. Otherwise, if your employer uses a Medical Provider Network (MPN) or a Health Care Organization (HCO), you will generally receive treatment within those networks unless you had predesignated your doctor or medical group. If no MPN or HCO is used by your employer, or if you did not predesignate, the claims administrator may choose the doctor for your initial treatment. After the first visit, you may have the right to switch doctors within the network under certain conditions.
What should I do if I disagree with the decision on my workers' compensation claim?
If you disagree with the decision about your workers' compensation claim, including the denial of a treatment recommended by your Primary Treating Physician (PTP), you may request an Independent Medical Review (IMR). Additionally, if there is a dispute about the nature or extent of your injury, you may need to be evaluated by a Qualified Medical Evaluator (QME). It's important to act quickly and to follow the appropriate steps to challenge the decision, which may include consulting with an attorney who specializes in workers' compensation law for guidance and representation.
One notable challenge individuals often face when filling out the DWC 1 form is neglecting to provide a complete description of their injury or illness, including every part of the body that is affected. This form serves as a critical component of the workers' compensation claim process, ensuring that the injured parties accurately and comprehensively detail the nature and extent of their injuries or illnesses. Failure to do so can lead to underestimation of the claim's severity, potentially affecting the scope of medical benefits and services they are entitled to receive. It is essential that individuals take the time to thoroughly document their injuries to facilitate a more accurate evaluation of their claim.
Another common oversight is not utilizing certified mail or a similar tracking service when submitting the DWC 1 form to their employer. This step is crucial for establishing a reliable record of the claim's submission, which can protect the injured party in the event of a dispute over whether the form was properly submitted. By opting for certified mail, individuals gain the ability to prove that the claim form was mailed and also track when it was delivered, thereby securing evidence that could be valuable in corroborating the timeline of events as reported.
Individuals often fail to keep a copy of the DWC 1 form for their records, which represents a significant misstep in managing their workers’ compensation claim. Retaining a personal copy ensures that they have immediate access to the information submitted, which can be especially useful during follow-up appointments or when seeking advice from a legal or medical professional. This record not only aids in maintaining personal responsibility over one’s claim but also serves as a point of reference for any future communications or disputes related to the claim.
The process of selecting and, if necessary, changing their primary treating physician (PTP) is another area where individuals often stumble. The DWC 1 form and its accompanying documentation outline the criteria and steps required for predesignating a personal physician or for switching to a different doctor within the network, should the need arise. Understanding these options and the associated timelines is vital for ensuring that individuals receive timely and appropriate medical care. Unfortunately, many overlook or misunderstand these provisions, potentially delaying their access to the medical treatments needed for their recovery.
A lack of awareness regarding the immediate authorization of up to $10,000 in medical treatment following the filing of the DWC 1 form is another common error. This entitlement allows for the commencement of necessary medical treatment while the claim is being evaluated, ensuring that individuals can access medical services without undue delay. Ignorance of this right means that some may not press for their immediate medical needs to be met, thereby hindering their recovery process.
Finally, individuals often miss the opportunity to utilize the resources available to them for resolving any problems or disputes that arise during the processing of their DWC 1 form and claim. The form mentions the ability to contact an Information & Assistance (I&A) Officer for guidance, yet many do not take advantage of this support. I&A Officers can provide valuable information and assistance, helping to navigate the complexities of the workers' compensation system, addressing concerns, and facilitating the resolution of issues that may impede the progress of a claim.
When dealing with workers' compensation claims, the DWC 1 form is a crucial document but it's often just the starting point in the filing process. Understanding other forms that may come into play can provide clarity and assist in navigating through workers' compensation seamlessly.
Navigating through the workers' compensation process involves managing an array of forms and documents that are necessary at various stages. While the DWC 1 form initiates the claim, understanding subsequent forms, such as those mentioned, is vital for both employees and employers. Proper completion and timely submission of these documents facilitate the claim process, ensuring that parties involved are adequately informed and protected under workers' compensation laws.
The DWC 1 form bears similarities to the Employee's Claim for Workers' Compensation Benefits Form (DWC-AD 10133.32), mainly in purpose and function. Both documents are integral to initiating a workers' compensation claim process, allowing employees to report work-related injuries or illnesses. Each formalizes the process for seeking compensation and medical benefits due to workplace injuries, offering a structured method for workers to convey the details of their injury or illness directly to employers and insurance carriers. The primary difference lies in specific requirements and instructions that each form may mandate according to the nature of the claim or the jurisdiction overseeing the workers' compensation process.
Another document that shares characteristics with the DWC 1 form is the Employer's Report of Occupational Injury or Illness (Form 5020). Although the DWC 1 is completed by the employee, and Form 5020 is filled out by the employer, both serve critical roles in the formal documentation and reporting process of a workers' compensation claim. They ensure that the incident is officially recorded, aiding in the review and determination process for benefits. By providing detailed information about the injury or illness, both forms help in the assessment and management of the claim by the insurer or claims administrator.
The Pre-Designation of Personal Physician Form is reminiscent of the DWC 1 form in that it relates closely to the workers' compensation claims process, particularly regarding medical treatment. This form allows employees to pre-designate their choice of a treating physician in the event of a work-related injury or illness. Similar to the DWC 1 form's section on medical care, the Pre-Designation form emphasizes the injured worker's right to receive medical treatment, albeit proactive in selection rather than reactive to an incident. Both documents enhance the worker's autonomy within their medical and compensation benefits, ensuring their preferences and needs are considered.
The Application for Adjudication of Claim (WCAB Form 1) shares similarities with the DWC 1 form as well, with both being part of the broader procedural framework for addressing disputes related to workers' compensation. While the DWC 1 form kickstarts the claims process after an injury, the Application for Adjudication can be filed when there is a disagreement regarding the claim between the employee and the employer or insurance carrier. Essentially, whereas the DWC 1 form is the starting block for benefits claims, the Application for Adjudication is a recourse when those claims do not proceed smoothly, signifying both their interconnectivity and distinct purposes within the workers' compensation system.
Lastly, the Notice of Potential Eligibility (NOPE) form often accompanies the DWC 1 and operates in tandem by informing the injured worker about their rights and the types of benefits they may be eligible for under workers' compensation law. This document complements the DWC 1 by providing essential information regarding the claims process, benefit entitlements, and legal rights. Both documents together ensure that the injured employee is fully equipped with the knowledge and means to initiate a claim, thereby facilitating an informed and efficient approach to accessing workers' compensation benefits.
When completing the DWC 1 form, there are certain practices you should follow to ensure the process goes smoothly and your claim is properly filed. Below are things you should and shouldn't do:
There are several misconceptions regarding the Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility that can lead to confusion for individuals who are navigating the workers’ compensation system for the first time. Here are four common misconceptions and the correct information:
Misconception 1: Submitting a DWC 1 Form Automatically Guarantees Compensation
Many believe that as soon as they submit the DWC 1 form, compensation for their injury or illness is guaranteed. However, submission of the form is just the first step in the claims process. The claims administrator must review the claim and determine eligibility based on the nature of the claim, the evidence provided, and applicable laws. Within 14 days, the administrator will notify the claimant if the claim has been accepted, denied, or if further investigation is necessary.
Misconception 2: You Can Only See a Doctor After Your Claim is Accepted
This is not true. Once the DWC 1 form is filed, employers or their claims administrators must authorize up to $10,000 in medical treatment for the injury while the claim is being evaluated. This ensures that you do not have to wait for claim acceptance to receive necessary medical care.
Misconception 3: The DWC 1 Form is Only for Physical Injuries
The form covers both physical and mental injuries or illnesses that are a result of one’s job, including injuries resulting from workplace crime. This broad coverage ensures that workers receive the care and compensation they are entitled to, regardless of the nature of their illness or injury.
Misconception 4: If You Don’t Have an Attorney, You Can’t Switch Doctors
Some claimants think that without an attorney, they are bound to the initial medical provider selected by the claims administrator or employer. However, injured workers have the right to change their medical provider within the network after their initial visit. Furthermore, if treatment is within a Medical Provider Network (MPN) or a Health Care Organization (HCO), you have options to switch providers within those frameworks. Prior to any injuries, workers also have the option to pre-designate their personal physician or medical group to treat any work-related injuries.
Understanding these facets of the Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility can make a significant difference in successfully navigating through the claims process and ensuring that workers receive the benefits and care they deserve.
Understanding how to properly fill out and use the DWC 1 form is critical for both employees and employers in managing workers' compensation claims efficiently. Here are 8 key takeaways:
Managed correctly, the DWC 1 form facilitates the workers' compensation process, ensuring employees receive the medical care and benefits entitled to them without unnecessary delay or confusion.
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