102 FORMS

102.1 Any notices, claims, requests, applications, or certificates that the Act or this chapter requires to be made shall be on approved forms.

102.2 All approved forms shall be obtained from the Program.

102.3 The following forms are approved:

1. (a) Form A-1 – Employee Request for Calculation and Certification of Award;
2. (b) Form 1 – Employee’s Notice of Injury / Claim for Continuation of Pay;
3. (c) Form CA1 – Request to Reinstate COP;
4. (d) Form 2 – Employing Agency’s Report of Injury / Response to COP Request;
5. (e) Form CA2 – Election of COP Charge Back;
6. (f) Form 3 – Physician’s Report;
7. (f-1) Form 3S – Supplemental Physician’s Report;
8. (g) Form 3RC – Annual Medical Recertification;
9. (h) Form 3A – Employee Statement of Medical History;
10. (i) Form CA3 – Employing Agency Report of Return to Work;
11. (j) Form 4 – Employee Authorization for Release of Medical Records;
12. (k) [Repealed];
13. (l) Form 6 – Employee Authorization for Release of PSWCP Records;
14. (m) Form 7 – Employee Request for PSWCP File;
15. (n) Form CA7, Part A – Employee Claim for Compensation;
16. (o) Form CA7, Part B – Employing Agency Statement;

1. (p) Form 8 – Employee Report of Earnings;
2. (q) Form 9 – Employee Application for Hearing Appeals Forms;
3. (q-1) Form 9A – Appeal to Chief Risk Officer;
4. (q-2) Form 9H – Request for Hearing before Chief Risk Officer;
5. (q-3) Form 9PH – Provider Request for Hearing;
6. (q-4) Form 9RC – Provider Request for Reconsideration;
7. (r) Form CA 10 – Request for Leave Restoration;
8. (s) Form 10 – Agreement to Off-set;
9. (t) Form 11 – Employee Request for Travel Reimbursement;
10. (u) Form 12 – Employee Claim for Permanent Disability Compensation;
11. (v) Form 12A – Employee Request for Hearing on Permanent Disability;
12. (v-1) Form 13 – Employee Request for Waiver or Appeal of Overpayment;
13. (v-2) Form 13F – Employee Financial Statement Form;
14. (v-3) Form 15 – Employee Representative Authorization Form;
15. (v-4) Form 16 – Employee Change of Address Form;
16. (w) Form MR – Request for Medical Reimbursement;
17. (x) [REPEALED];
18. (y) Form M3 – Request to Change Treating Physician; and
19. (z) Form M4 – Request for Pre-authorization of Medical Procedure.

102.4 Nothing in this section shall be construed to limit the number of forms approved by the Program.

SOURCE: Final Rulemaking published at 28 DCR 2307 (May 22, 1981); as amended by a Emergency and Proposed Employment Benefits

Rulemaking published at 57 DCR 9540 (October 8, 2010)[EXPIRED]; as amended by a Final Rulemaking published at 57 DCR 12224 (December 24, 2010); as amended by Final Rulemaking published at 59 DCR 8766, 8767 (July 27, 2012); as amended by Final Rulemaking published at 64 DCR 6325 (July 7, 2017); as amended by Final Rulemaking published at 66 DCR 4246 (April 5, 2019).