The Doctor's First Report, the PR-2 progress report, the Request for Authorization and the permanent and stationary reports, plus the QME forms, with who completes each.
California's Division of Workers' Compensation (DWC) sets the forms a treating physician uses from the first visit to the permanent and stationary report. The Doctor's First Report of Occupational Injury or Illness (Form 5021) comes first. The Primary Treating Physician's Progress Report (PR-2) follows at least every 45 days, and the Request for Authorization (DWC Form RFA) asks the claims administrator to approve treatment, which triggers utilization review. Once the condition is permanent and stationary, the PR-4 reports permanent disability.
Form 5021 goes to the employer's insurer within 5 days of the first exam, and the signature must be original, not a stamp. The PR-2 is billed under OMFS code WC002, while Form 5021 is included in the visit. Panel QMEs use the QME Form 110 appointment notice, the QME Form 111 findings summary in unrepresented cases and the QME Form 122 proof of service. Of the forms here, only the Notice of Predesignation of Personal Physician (DWC Form 9783) has a Spanish version.
Initial physician report of every occupational injury or illness: history, findings, ICD-10 diagnoses, treatment and work status.
DWC Form PR-2Periodic or event-driven progress report from the primary treating physician on findings, diagnoses, treatment plan and work status.
DWC Form RFAPhysician's request to the claims administrator to authorize specific medical treatment, goods or services, triggering utilization review.
Treating physician's initial evaluation of permanent disability (whole person impairment, apportionment, work restrictions, future medical care) once the patient is permanent and stationary.
DWC-AD 10133.36Tells the employer the permanent work capacities and activity restrictions so it can offer regular, modified or alternative work or issue the Supplemental Job Displacement voucher.
DWC Form 9783Aviso de Designación Previa de Médico Personal
Employee's advance designation of a personal physician or medical group to treat a future work injury, with the physician's agreement.
Treating physician's permanent and stationary report for disability ratings under the older 1997 Permanent Disability Rating Schedule.
Asks the Disability Evaluation Unit to rate a panel QME's report in an unrepresented case.
Licensed provider's declaration that an attached mental health record must not be seen or copied by the injured employee because of substantial risk of harm (Health & Safety Code 123115(b)).
QME Form 110Panel QME's notice to the parties of the scheduled comprehensive medical-legal evaluation.
Proof of service of a comprehensive medical-legal report on each party (Labor Code 4062.3(i)).
Summary of the panel QME's conclusions on disputed medical issues (P&S status, impairment, causation, apportionment, future care, return to work) in unrepresented cases.
QME Form 112Evaluator's request for a 30-day extension to serve a medical-legal report (e.g. lab or test results not received).
QME Form 123Evaluator's disclosure of a disqualifying conflict of interest (or statement that none exists) in a specific case, with the parties' objection or waiver.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Within 5 days of the initial exam. Send two copies to the employer's workers' compensation insurer, or to the insured employer. Pesticide cases are also reported to DIR and the local health officer by phone within 24 hours. The physician signs under penalty of perjury with an original signature, not a stamp, and late filing carries a civil penalty. Form 5021 has no Spanish version.
At least every 45 days, and whenever the condition, treatment plan or work status changes, a referral or surgery is needed, or the patient is released from care. The primary treating physician sends it to the claims administrator, and a narrative report can replace or supplement it. The PR-2 is billed under OMFS code WC002 and is often attached to a DWC Form RFA. It is not used once the patient is permanent and stationary.
Mail, fax or email it to the claims administrator with a supporting Form 5021, PR-2 or narrative report. One RFA can request up to five procedures, and an expedited review box covers imminent threats to the patient's health. The request goes through utilization review, and if it is denied, the employee can appeal through Independent Medical Review, whose application comes in English and Spanish.
The Physician's Return-to-Work & Voucher Report (DWC-AD 10133.36), for injuries on or after January 1, 2013. The first physician, whether PTP, QME or AME, to find all conditions permanent and stationary with permanent partial disability attaches it to that report. It lists permanent work capacities and restrictions so the employer can offer work or issue the Supplemental Job Displacement voucher. Its payment is bundled into the PR-3 or PR-4.