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DEPARTMENT OF FINANCIAL SERVICES Division of Workers' Compensation DFS-F5-DWC-90 (UB-04) — C Completion Instructions Ambulatory Surgical Centers shall complete the DFS-F5-DWC-90 (UB-04) according

How to fill out dwc 90 form

How to fill out dwc 90 form:

1. First, gather all necessary information and documentation such as your personal details, employer information, and the nature of your injury or illness.
2. Begin by filling out the top section of the form, which requires your name, address, and contact information.
3. Provide your employer's information, including their name, address, and contact details.
4. Next, carefully fill in the details of your injury or illness, including the date, time, and location of the incident.
5. Describe the specific body parts affected and the nature of the injury or illness in detail.
6. If there were witnesses to the incident, include their names and contact information.
7. Indicate whether any medical treatment was received, including the dates and names of the healthcare providers.
8. Sign and date the form after reviewing all the information for accuracy.
9. Make a copy of the completed form for your records before submitting it to the appropriate parties.

Who needs dwc 90 form:

1. Employees who have suffered a work-related injury or illness may need to fill out a dwc 90 form.
2. Employers are typically required to provide this form to their employees who have been injured or fallen ill on the job.
3. Healthcare providers may also need to complete sections of the form when treating an injured or ill employee, providing relevant medical information and treatment details.

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What is dwc 90 form?

The DWC 90 form is a document used in workers' compensation cases in California to notify the Division of Workers' Compensation that an injured worker is requesting a claim.

Who is required to file dwc 90 form?

Employers or insurance carriers are required to file the DWC 90 form when an injured worker submits a claim for workers' compensation benefits.

How to fill out dwc 90 form?

To fill out the DWC 90 form, you should provide details about the injured worker, the nature of the injury, the date of the incident, and any relevant employer and insurance information.

What is the purpose of dwc 90 form?

The purpose of the DWC 90 form is to formally communicate the initiation of a workers' compensation claim to the Division of Workers' Compensation.

What information must be reported on dwc 90 form?

The DWC 90 form must report the injured worker's name, address, date of injury, type of injury, employment details, and information about the employer and insurance carrier.