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Purpose of Medical Forms


Notification of Claim of Compensable Injury  Form DWC 29 Revised 4/02

Health care providers are required to submit this notice to the insurer within three days of an initial visit following an injury. The health care provider may charge the insurer a twenty dollar ($20.00) fee for each timely filed form.  A copy should be sent to the employee and his or her attorney.


Physician's Notice of Release to Work    Form DWC 27/28 Revised 4/02

Health care providers are required to submit this notice of release to work to the insurer within three days of the injured employee's release, discharge, return to work, and/or recovery from an injury. The health care provider may charge the insurer a twenty dollar ($20.00) fee for each timely filed form.  A copy should be sent to the employee and his or her attorney.


Request for Additional Palliative Care   Form DWC 40 Revised 04/05

Health care providers are required to submit this request for additional palliative care to the insurer for authorization.

 

 




 
RI Department of Labor and Training
Workers' Compensation
Center General Complex
1511 Pontiac Avenue, Cranston, RI 02920


Phone: (401) 462-8100
Fax (401) 462-8105
TTY via RI Relay: 711
1/27/14 MDF
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  DLT is an equal opportunity employer/program. Auxiliary aids and services available upon request