Workers' Compensation Forms & Documents

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Workers Comp Injury Packet

Download/unzip all Injury Packet Forms (1.3MB ZIP, updated 11/27/2018)

Workers Comp General Forms

Employer's Report of Occupational Injury or Illness (5020) (PDF)
This is the employer's report of industrial injury. The employing department prepares it and sends it to Workers' Compensation Services as soon as possible after the employing department is notified of the injury.

Supervisor's Investigation Report (PDF)
The supervisor of the ill or injured employee should complete this report within 24 hours of the first notification of injury or illness. The report is intended to afford the supervisor an opportunity to evaluate the cause of the injury and what corrective action can be taken to prevent a recurrence. The report is sent to Workers' Compensation Services by the employing departments.

Employee's Claim for Workers' Compensation Benefits (DWC-1) (PDF)
The injured employee completes the top portion of the form and gives it to the employing department, who will complete the bottom portion. The completed form is sent to Workers' Compensation Services. Workers' Comp has up to 90 days to investigate the injury and either accept or deny the claim.

Medical Mileage Reimbursement Form (DIR Website)
Use this form to request Reimbursement for Medical Mileage Expenses. If you have to travel to get treatment for your work injury, you are entitled to re-payment of your travel costs.

Continuity of Care Notice (PDF,  updated 12/9/08) 
This form letter is sent to the injured worker by the adjuster and explains the procedure that is to be followed regarding continuing medical care that will be provided after the treatment by the pre-designated physician terminates.

Second or Third Opinion Request (PDF,  updated 3/23/12) 
This explains the procedure to be followed for obtaining second or third opinions.

Employee Pre-designation of Workers' Compensation Physician (114.9KB PDF, updated 3/23/2012)
This allows the employee to select a primary treating physician from the County's health plan prior to incurring an industrial injury or illness. Conditions governing the selection of the physician are described on the form. The employee completes the form and gives it to the employing department. The employing department provides a copy to Workers' Compensation Services in the event of a work-related injury or illness.

Request for Medical Service - Industrial Injury (254.3KB PDF, updated 10/19/2018)
Authorization for treatment by a primary treating physician. The employing department prepares the form and gives it to the injured employee when notified of the injury. A copy of the completed form is sent by the department to Workers' Compensation Services.

Authorization for the Release of Information (115.2KB PDF, updated 7/23/2018)
This form allows Workers' Compensation Services to obtain information relevant to the claim. The injured employee completes the form when the injury or illness is reported, and gives it to Workers' Compensation Services.

Authorization for the Release of Information - Kaiser (207.5KB PDF, updated 10/16/2013)
This is the Kaiser version of the form above.

Express Scripts Form for Prescription for First Fill (246.6KB PDF, updated 6/14/2017)
Injured Worker Fork form Express Scripts for First Fill of Prescriptions and Temporary ID Card.

Workers Comp Informational Documents

Explanation of "Sick Leave Use" Option (128.5KB PDF, updated 6/13/2007)
The County allows injured employees to use their accrued sick leave in lieu of temporary disability benefits in the event the employee loses time from work as a result of an industrial injury or illness. The form explains the two options available to the injured employee. The form is to be completed by the employee at the time the injury is reported to the employing department. The completed form is sent to the Auditor and Workers' Compensation Services by the injured employee or employing department

Employee Notification of Medical Provider Network (PDF,  updated 4/29/14) 
This is a list of medical and ancillary providers of medical services that comprise the Medical Provider Network.

Expedited Resolution Process (ERP) Forms & Documents

ERP - IME Request for Application (105KB DOC, updated 11/30/2016)
For ERP only. Request Independent Medical Examiner Application

ERP Description (59.7KB RTF, updated 6/1/2017)
County of Kern Workers’ Compensation Expedited Resolution Process (ERP) Program Description. This program is designed to enhance benefit delivery systems and accelerate the time in which disputes are resolved.

ERP FACT SHEET C TD (65.5KB RTF, updated 6/1/2017)
Fact sheet C answers to your questions about temporary disability benefit. Temporary disability (TD) benefits are payments you get if you lose wages because your injury prevents you from doing your usual job while recovering.

ERP FACT SHEET D PD (120.4KB RTF, updated 6/1/2017)
Fact sheet D answers to your questions about permanent disability benefit. Permanent disability (PD) is any lasting disability from your work injury or illness that affects your ability to earn a living. If your injury or illness results in PD you are entitled to PD benefits, even if you are able to go back to work.

ERP FACT SHEET E IME (77.5KB RTF, updated 6/1/2017)
Fact sheet E answers to your questions about independent medical examiners. Independent Medical Examiners (IME) examine injured workers to determine the benefits they will receive if there is a disagreement over the treating physician’s opinions.

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