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Form DFS-F5-DWC-9 B Completion Instructions Submitted by Ambulatory Surgical Centers A. Header Information Health Care Providers shall enter Insurer/Carrier name, address and zip code in the blank

How to fill out dwc 9 form

How to fill out DWC 9 form:

1. Obtain a copy of the DWC 9 form. It can be downloaded from the official website of the Division of Workers' Compensation (DWC) or obtained from your employer or insurance provider.
2. Provide your personal information. Fill in your full name, address, contact number, and email address in the designated sections of the form.
3. Enter your employer's details. Include your employer's name, address, and contact information in the appropriate fields. If you have multiple employers, you may need to provide information for each one separately.
4. Specify the date of your injury or illness. Indicate the exact date when your work-related injury or illness occurred. Be as accurate as possible to ensure timely processing of your claim.
5. Describe your injury or illness. Write a detailed account of the nature and extent of your injury or illness. Include information such as how it occurred, the body part affected, and any medical treatment received.
6. Provide your medical provider's information. Include the name, address, and contact details of the healthcare professional who treated you for your work-related injury or illness.
7. Attach relevant medical documentation. Include any medical reports, test results, or treatment records that support your claim. This can help substantiate the severity and impact of your injury or illness.
8. Sign and date the form. After completing all the necessary information, carefully review the form and sign it at the designated area. Ensure that the form is dated accurately.

Who needs DWC 9 form:

1. Employees who have sustained a work-related injury or illness. The DWC 9 form is intended for individuals who have experienced harm or developed an illness as a direct result of their employment.
2. Employers and insurance providers. The DWC 9 form is also required for employers and insurance providers to process workers' compensation claims and determine the appropriate benefits and compensation to be provided.
3. Healthcare professionals. Medical providers who have treated individuals for work-related injuries or illnesses may also need to complete sections of the DWC 9 form to document the details of the treatment and prognosis.

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What is dwc 9 form?

The DWC 9 form is a document used in workers' compensation cases to report medical treatment provided to injured employees.

Who is required to file dwc 9 form?

Healthcare providers and insurance carriers are generally required to file the DWC 9 form when medical treatment is provided to injured employees in workers' compensation cases.

How to fill out dwc 9 form?

To fill out the DWC 9 form, healthcare providers or insurance carriers must include information such as the injured employee's name, date of birth, date of injury, treatment provided, and other details related to the medical treatment.

What is the purpose of dwc 9 form?

The purpose of the DWC 9 form is to ensure proper documentation and reporting of medical treatment provided to injured employees in workers' compensation cases. It helps track the medical progress and expenses related to the injury.

What information must be reported on dwc 9 form?

The DWC 9 form requires reporting of various information including the injured employee's name, date of birth, date of injury, treatment provided, medical provider's information, diagnosis codes, and billing details.