policyholder-banner

MPN Information

Medical Provider Network (MPN)

This form notifies employees how to access medical care as well as their rights and responsibilities in accordance with the latest California laws (SB899).

English

policyholder-banner

Reference Information

DWC Fact Sheets 

DWC Fact Sheets are documents that can be used by both the injured workers and the Policyholders to provide an overview of the laws that govern the claims administration process in the State of California. These forms are also available on the DWC website at www.dir.ca.gov

Employee Fact Sheet – English | Spanish

Fact Sheet A: Utilization Review Fact Sheet – English | Spanish

Fact Sheet B: Glossary of Workers’ Comp Terms – English | Spanish

Fact Sheet C: Temporary Disability Fact Sheet – English | Spanish

Fact Sheet D: Permanent Disability Fact Sheet – English | Spanish

Fact Sheet E: Qualified Medical Evaluation/Agreed Medical Evaluation Fact Sheet – English | Spanish

Medical Records Release of Injured Worker 

When injured workers sign this form, they give PacificComp permission to obtain their medical records so that PacificComp can evaluate their claim.

English | Spanish | English and Spanish

Mileage Reimbursement Request for Injured Worker Use 

Injured workers should use this form to log their mileage for travel related to their medical treatment so that PacificComp can reimburse them.

English and Spanish

policyholder-banner

After a Claim Occurs

Accident Investigation Report of Supervisor 

This form should be used by the injured worker’s supervisor to evaluate the reported incident and secure a statement of a worker’s injury.

English and Spanish

Employee’s Claim for Workers’ Compensation Benefits (DWC1)

When the employee turns in the DWC1 form to the employer:

  • Injured workers must complete the first section of the DWC1 form and give it to their Employer.
  • The employee should make and keep a copy before the Employer has filled it out. This is called a temporary copy.
  • Once the employer has completed its portion, one copy should be given to the employee, one to PacificComp and one retained for the file.

English and Spanish

Employee Medical Care Refusal and DWC1 Receipt 

When an employee refuses medical care, this form should be used to document a refusal of medical attention and acknowledge that the employee was provided with a DWC1 Workers’ Compensation Claim form.

English and Spanish

Employers Report of Occupational Injury Form 5020

Policyholders should complete this form for all injuries reported to PacificComp. This 5020 form can also be completed for the Policyholder when a claim is reported using PacificComp’s 24-hour Injury Hotline (800-474-8080).

English

Initial Medical Referral to Physician from Policyholder 

Employers should send this form with the employee to the industrial clinic to advise that modified duty is available.

English

Wage Statement Form to Be Completed by Policyholder

Employers should use this form to list an injured worker’s weekly earnings in the year before the injury occurred. PacificComp bases its benefit payment to the injured worker in large part on that person’s earning history.

English

policyholder-banner

Pharmacy Benefit Manager Program

Your pharmacy program services for your workers’ compensation prescriptions will be handled through Express Scripts.

In your Claim Kit, you were provided with information related to this program as well as a temporary prescription ID card to provide your injured employees.

A new Express Scripts prescription-drug ID card will be sent to your employee when the claim is filed. They should use the Express Scripts card at any Express Scripts Workers’ Compensation participating pharmacy.

An Express Scripts Customer Service patient care advocate is available 24/7 at 1-800-945-5951.

policyholder-banner

Before an Injury Occurs

Employee Physician Pre-Designation Form

This form allows employees to designate the physician who they want to receive treatment from in the event of a workplace injury or illness. We recommend this be included as part of an employee on-boarding process or included in the Human Resources (HR) handbook. When completed, this form should be submitted to the employee’s HR Department and maintained in their personnel file. It must be completed prior to an injury to be valid.

English | Spanish

Employee Pre-Designation Form for Personal Chiropractor or Acupuncture

If you are not currently enrolled in a PacificComp Medical Provider Network (MPN), your employees can pre-designate a chiropractor or acupuncturist after the employee obtains initial treatment with your employer-designated physician. The employer is then required to allow the employee to go to his/her pre-designated physician. This form can be used for notice, and it must be completed prior to an injury to be valid.

English | Spanish

Posting Notice for Policyholder (DWC-7)

California law requires that all employers post a copy of this document at the place(s) where employee notices are usually posted. It summarizes employees’ rights with regard to workers’ compensation benefits, steps to take in the event of an injury, and your company’s PacificComp MPN and claims information.

English | Spanish

Return to Work Program of Policyholder

Employers use this form to notify new employees of the return-to-work program. It may be included in your HR handbook.

English