Guía 18 de la Unidad de Información y Asistencia

I&A 18 (Sp) Rev. 11/14

Cómo llenar una hoja de separador de documento

Además de la hoja de portada de documento (consulte la guía 17 de I&A) todos los formularios presentados ante su oficina regional de la Junta de Apelaciones de Compensación de Trabajadores (Workers’ Compensation Appeals Board - WCAB) necesitan una “hoja de separador de documento.” Necesitamos la hoja de separador de documento para que la información en el formulario que sigue pueda ser leída por nuestro Sistema de Manejo de Adjudicación Electrónica (Electronic Adjudication Management System- EAMS).

La hoja de separador es requerida aún si sólo está presentando un documento. Esto significa que usted presentará por lo menos tres documentos, en el siguiente orden, con lo que sea presentado en la WCAB: 1. Una hoja de portada de documento2. Una hoja de separador de documento3. El formulario que necesita presentar

Si usted está presentando documentos justificativos con su formulario, necesitará hojas de separador para identificarlos.

Puede llenar la hoja de separador de documento que está adjunto utilizando una máquina de escribir o a mano utilizando letra de molde. Este formulario también puede ser llenado en línea en: www.dir.ca.gov/dwc/FORMS/EAMS%20Forms/ADJ/DWCCAform10232_2.pdf.

Utilice el ejemplo adjunto como guía.

Tenga en cuenta que la hoja de separador proporciona la información sobre el documento que la sigue. Para llenar la hoja de separador:

Seleccione la “unidad de la entrega del producto” (product delivery unit- launidad que recibirá su formulario o documento) correcta. Debe seleccionarADJ, DEU, RSU, VOC, o INT. Por favor consulte el apéndice y el ejemplopara más información

Seleccione el “tipo de documento” (document type) para la entrega delproducto elegido. Consulte con el apéndice para los tipos de documentosdisponibles en cada unidad de la entrega del producto. Por ejemplo bajoADJ, los únicos cuatro tipos de documentos son: documento legal, embargospreventivos y facturas, documento médico, y misceláneo. SÓLO utilice lasopciones proporcionadas. No escriba ningún tipo de documento que noexiste para la unidad. Si usted está llenando la hoja de separador en el sitioWeb, las opciones disponibles se encuentran en un menú desplegable en elformulario

Guía 18 de la Unidad de Información y Asistencia

I&A 18 (Sp) Rev. 11/14

Seleccione el “título de documento” (document title) del apéndice. Una vezmás, utilice SÓLO las opciones proporcionadas. No escriba ningún título dedocumento que no existe para la unidad ni tipo de documento que haseleccionado. Si está llenando la hoja de separador en el sitio Web, lasopciones disponibles se encuentran en un menú desplegable en el formulario

Ponga la “fecha del documento” (document date- como la fecha del informemédico o la fecha de una carta) utilizando dos dígitos para los meses y díasy cuatro dígitos para los años. El mes, día y año deben estar separados porun diagonal, así: 02/15/2008.

Ponga el nombre de la persona u organización que escribió el documento enla casilla que dice “autor” (author). Por ejemplo si el documento siguiendola hoja de separador es un informe médico, el médico es el autor. Si suadministrador de reclamos es el autor, necesita saber el “nombre uniformeasignado” (uniform assigned name) de esa compañía para ponerlo en esacasilla. Usted puede encontrar el nombre uniforme asignado de suadministrador de reclamos en el sitio Web enhttp://www.dir.ca.gov/DWC/EAMS/EAMS-LC/EAMSClaimsAdmins.asp

Envíe el paquete de los documentos completos a la oficina regional de la WCAB local apropiada. Las direcciones y los números de teléfono de las oficinas regionales de la WCAB están adjuntos a esta guía.

Instrucciones adicionales para presentar formularios en EAMS se pueden encontrar en línea en el “EAMS OCR forms handbook” (Manual de formularios OCR de EAMS) en http://www.dir.ca.gov/dwc/EAMS/SampleFiles/EAMS_OCR%20handbook.pdf.

Si usted necesita ayuda, llame a una oficina de Información y Asistencia (I&A) o asista a un taller para trabajadores lesionados. Los números de teléfono de las oficinas locales de I&A están adjuntos a esta guía. Usted puede obtener información sobre un taller local de la oficina de I&A o en el Internet en www.dwc.ca.gov.

La información contenida en esta guía es de índole general y no pretende substituir asesoramiento legal. Los cambios en la ley o los datos específicos de su caso podrían resultar en interpretaciones legales distintas de las que aquí se presentan.

Al enviar documentos a una oficina regional, por favor asegúrese que no estén doblados ni engrapados. Envíelos en un sobre grande de manila. Por favor consulte con el manual de formularios OCR de EAMS para instrucciones adicionales.

WORKERS’ COMPENSATION APPEALS BOARD DISTRICT OFFICES

ANAHEIM, 92806-2131 SACRAMENTO, 95834-2962 1065 N PacifiCenter Drive, Suite 170 160 Promenade Circle, Suite 300 Information & Assistance Unit (714) 414-1800 Information & Assistance Unit (916) 928-3158 BAKERSFIELD, 93301-1929 SALINAS, 93906-2204 1800 30th Street, Suite 100 1880 N Main Street, Suites 100 & 200 Information & Assistance Unit (661) 395-2514 Information & Assistance (831) 443-3058 EUREKA, 95501-0481 * Satellite office * SAN BERNARDINO, 92401-1411 100 “H” Street, Suite 202 464 W Fourth Street, Suite 239 Information & Assistance Unit (707) 441-5723 Information & Assistance Unit (909) 383-4522 FRESNO, 93721-2219 SAN DIEGO, 92108-4424 2550 Mariposa Street, Suite 4078 7575 Metropolitan Drive, Suite 202 Information & Assistance Unit (559) 445-5355 Information & Assistance Unit (619) 767-2082 LONG BEACH, 90802-4339 SAN FRANCISCO, 94102-7014 300 Oceangate Street, Suite 200 455 Golden Gate Avenue, 2nd Floor Information & Assistance Unit (562) 590-5240 Information & Assistance Unit (415) 703-5020 LOS ANGELES, 90013-1105 SAN JOSE, 95113-1402 320 W 4th Street, 9th Floor 100 Paseo de San Antonio, Suite 241 Information & Assistance Unit (213) 576-7389 Information & Assistance Unit (408) 277-1292 MARINA DEL REY, 90292-6902 SAN LUIS OBISPO, 93401-8736 4720 Lincoln Boulevard, 2nd and 3rd floors 4740 Allene Way, Suite 100 Information & Assistance Unit (310) 482-3858 Information & Assistance Unit (805) 596-4159 OAKLAND, 94612-1499 SANTA ANA, 92701-4070 1515 Clay Street, 6th Floor 605 W Santa Ana Boulevard, Bldg 28, Suite 451 Information & Assistance Unit (510) 622-2861 Information & Assistance Unit (714) 558-4597 OXNARD, 93030-7912 SANTA BARBARA, 93101-7538 * Satellite office * 1901 N Rice Avenue, Suite 100 130 E Ortega St. Information & Assistance Unit (805) 485-3528 Information & Assistance Unit (805) 568-1390 POMONA, 91768-1653 SANTA ROSA, 95404-4771 732 Corporate Center Drive 50 “D” Street, Suite 420 Information & Assistance Unit (909) 623-8568 Information & Assistance Unit (707) 576-2452 REDDING, 96002-0940 STOCKTON, 95202-2314 250 Hemsted Drive, 2nd Fl, Ste. B 31 E Channel Street, Suite 344 Information & Assistance Unit (530) 225-2047 Information & Assistance Unit (209) 948-7980 RIVERSIDE, 92501-3337 VAN NUYS, 91401-3370 3737 Main Street, Suite 300 6150 Van Nuys Boulevard, Suite 105 Information & Assistance Unit (951) 782-4347 Information & Assistance Unit (818) 901-5374 Rev. 5/16

DOCUMENT SEPARATOR SHEET

MM/DD/YYYY

MM/DD/YYYY

Office Use Only

DWC-CA form 10232.2 Rev. 4/2014 Page 1

Author

Document Date

Received Date

Product Delivery Unit

Document Type

Document Title

DOCUMENT SEPARATOR SHEET

MM/DD/YYYY

MM/DD/YYYY

Office Use Only

DWC-CA form 10232.2 Rev. 4/2014 Page 1

Author

Document Date

Received Date

Product Delivery Unit

Document Type

Document Title

Product Delivery Document type Document TitleADJ IBR APPEAL OF DETERMINATION OF AD-IBRADJ IMR APPEAL OF DETERMINATION OF AD-IMR

ADJ LEGAL DOCS 10770.5 VERIFICATIONADJ LEGAL DOCS 10770.6 VERIFICATIONADJ LEGAL DOCS 132AADJ LEGAL DOCS 1990 - 1993 WINDOW PERIOD APPLICATIONADJ LEGAL DOCS 1990 - 1993 WINDOW PERIOD APPLICATION - DEATH CLAIMADJ LEGAL DOCS 4906(g) DECLARATIONADJ LEGAL DOCS AMENDED APPLICATION FOR ADJUDICATIONADJ LEGAL DOCS AMENDED APPLICATION FOR ADJUDICATION-DEATHADJ LEGAL DOCS AMENDED COMPROMISE AND RELEASEADJ LEGAL DOCS AMENDED STIPULATIONSADJ LEGAL DOCS ANSWERADJ LEGAL DOCS ANSWER TO 132AADJ LEGAL DOCS ANSWER TO APPLICATION FOR ADJUDICATION OF CLAIMADJ LEGAL DOCS ANSWER TO PETITION FOR RECONSIDERATIONADJ LEGAL DOCS ANSWER TO PETITION FOR REMOVALADJ LEGAL DOCS ANSWER TO S & WADJ LEGAL DOCS APPEAL OF DETERMINATION OF AD-OTHERADJ LEGAL DOCS APPEAL OF DETERMINATION OF AD-RSUADJ LEGAL DOCS APPLICATION FOR ADJUDICATIONADJ LEGAL DOCS APPLICATION FOR ADJUDICATION-DEATHADJ LEGAL DOCS APPLICATION FOR SUBSEQUENT INJURIES FUND BENEFITSADJ LEGAL DOCS ARBITRATION SUBMITTAL FORMADJ LEGAL DOCS BENEFIT NOTICEADJ LEGAL DOCS BENEFIT PRINTOUTADJ LEGAL DOCS BIRTH CERTIFICATEADJ LEGAL DOCS C&R: RESPONSE TO LETTER REQUESTING INFORMATIONADJ LEGAL DOCS CHANGE OF ADDRESSADJ LEGAL DOCS CHANGE OF HANDLING LOCATIONADJ LEGAL DOCS COMPROMISE AND RELEASEADJ LEGAL DOCS COMPROMISE AND RELEASE DEPENDENCY CLAIMADJ LEGAL DOCS COMPROMISE AND RELEASE: WALK THROUGH SETTLEMENT

Document Titles List (Rev. 4/2014) updated 7/29/2014 1

Product Delivery Document type Document TitleADJ LEGAL DOCS DEATH CERTIFICATEADJ LEGAL DOCS DECLARATION OF READINESS TO PROCEED

ADJ LEGAL DOCS DECLARATION OF READINESS TO PROCEED TO EXPEDITED HEARINGADJ LEGAL DOCS DEPOSITION TRANSCRIPTADJ LEGAL DOCS DISMISSAL OF ATTORNEYADJ LEGAL DOCS DWC-1 CLAIM FORMADJ LEGAL DOCS FEE DISCLOSURE STATEMENTADJ LEGAL DOCS MARRIAGE LICENSEADJ LEGAL DOCS MINUTES OF HEARINGADJ LEGAL DOCS NOTICE OF CHANGE IN REPRESENTATIONADJ LEGAL DOCS NOTICE OF CHANGE OF ADMINISTRATORADJ LEGAL DOCS NOTICE OF NON-REPRESENTATIONADJ LEGAL DOCS NOTICE OF OFFER OF REGULAR WORK ADJ LEGAL DOCS NOTICE OF PERMANENT DISABILITY BENEFITSADJ LEGAL DOCS NOTICE OF POTENTIAL SJDBADJ LEGAL DOCS NOTICE OF REPRESENTATIONADJ LEGAL DOCS NOTICE OF TEMPORARY DISABILITY BENEFITS (DWC 500-B)ADJ LEGAL DOCS NOTICE REGARDING MPNADJ LEGAL DOCS OBJECTION - OTHERADJ LEGAL DOCS OBJECTION TO DECLARATION OF READINESS TO PROCEEDADJ LEGAL DOCS OBJECTION TO PETITION/REQUEST FOR DISMISSAL

ADJ LEGAL DOCSOBJECTION TO PETITION TO TERMINATE LIABILITY FOR TEMPORARY DISABILITY

ADJ LEGAL DOCS OBJECTION TO VENUEADJ LEGAL DOCS PETITION - OTHER

ADJ LEGAL DOCSPETITION BY NON-PHYSICIAN LIEN CLAIMANT FOR MEDICAL INFORMATION

ADJ LEGAL DOCS PETITION FOR APPOINTMENT OF GUARDIAN AD LITEM

ADJ LEGAL DOCS PETITION FOR APPOINTMENT OF REPLACEMENT QMEADJ LEGAL DOCS PETITION FOR APPOINTMENT OF REPLACEMENT QME PANELADJ LEGAL DOCS PETITION FOR ATTORNEY FEESADJ LEGAL DOCS PETITION FOR AUTOMATIC REASSIGNMENT

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Product Delivery Document type Document TitleADJ LEGAL DOCS PETITION FOR CERTIFICATIONADJ LEGAL DOCS PETITION FOR CHANGE OF GUARDIAN AD LITEMADJ LEGAL DOCS PETITION FOR CHANGE OF VENUEADJ LEGAL DOCS PETITION FOR COMMUTATIONADJ LEGAL DOCS PETITION FOR CONSOLIDATIONADJ LEGAL DOCS PETITION FOR CONTRIBUTIONADJ LEGAL DOCS PETITION FOR COSTSADJ LEGAL DOCS PETITION FOR CREDIT FOR OVERPAYMENT OF BENEFITSADJ LEGAL DOCS PETITION FOR DEPOSITION ATTORNEY FEE (LC 5710)

ADJ LEGAL DOCS PETITION FOR DEPOSITION ATTORNEY FEE (LC 5710) - WALKTHROUGHADJ LEGAL DOCS PETITION FOR DISCOVERY ORDERADJ LEGAL DOCS PETITION FOR DISMISSALADJ LEGAL DOCS PETITION FOR DISMISSAL OF A PARTYADJ LEGAL DOCS PETITION FOR DISQUALIFICATIONADJ LEGAL DOCS PETITION FOR FINDING OF FACT

ADJ LEGAL DOCSPETITION FOR INCREASED BENEFITS FOR SERIOUS AND WILLFUL MISCONDUCT

ADJ LEGAL DOCS PETITION FOR JOINDERADJ LEGAL DOCS PETITION FOR ORDER ASSIGNING SECOND PANEL QME

ADJ LEGAL DOCS PETITION FOR ORDER COMPELLING SERVICE OF MEDICAL RECORDADJ LEGAL DOCS PETITION FOR ORDER CORRECTING CLERICAL ERRORADJ LEGAL DOCS PETITION FOR ORDER OF CONFIDENTIALITYADJ LEGAL DOCS PETITION FOR ORDER OF PUBLICATIONADJ LEGAL DOCS PETITION FOR PENALTIESADJ LEGAL DOCS PETITION FOR RECONSIDERATIONADJ LEGAL DOCS PETITION FOR RECONSIDERATION/REMOVALADJ LEGAL DOCS PETITION FOR REHAB ATTORNEY FEEADJ LEGAL DOCS PETITION FOR REHAB ATTORNEY FEE - WALKTHROUGHADJ LEGAL DOCS PETITION FOR REMOVALADJ LEGAL DOCS PETITION FOR RESTITUTIONADJ LEGAL DOCS PETITION FOR SANCTIONS/COSTADJ LEGAL DOCS PETITION FOR STAY OF PROCEEDINGS

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Product Delivery Document type Document TitleADJ LEGAL DOCS PETITION FOR THIRD PARTY CREDITADJ LEGAL DOCS PETITION FOR THIRD PARTY CREDITADJ LEGAL DOCS PETITION FOR WRIT OF ATTACHMENTADJ LEGAL DOCS PETITION FOR WRIT OF ATTACHMENTADJ LEGAL DOCS PETITION TO BAR RECEIPT OF BENEFITSADJ LEGAL DOCS PETITION TO BAR RECEIPT OF BENEFITSADJ LEGAL DOCS PETITION TO BE RELIEVED AS ATTORNEY OF RECORDADJ LEGAL DOCS PETITION TO BE RELIEVED AS ATTORNEY OF RECORDADJ LEGAL DOCS PETITION TO CHANGE ADMINISTRATOR OF AWARDADJ LEGAL DOCS PETITION TO CHANGE ADMINISTRATOR OF AWARD

ADJ LEGAL DOCS PETITION TO COMPEL ATTENDANCE AT MEDICAL EVALUATION

ADJ LEGAL DOCS PETITION TO COMPEL ATTENDANCE AT MEDICAL EVALUATION

ADJ LEGAL DOCSPETITION TO COMPEL ATTENDANCE AT MEDICAL EVALUATION - WALKTHROUGH

ADJ LEGAL DOCSPETITION TO COMPEL ATTENDANCE AT MEDICAL EVALUATION - WALKTHROUGH

ADJ LEGAL DOCS PETITION TO COMPEL DEPOSITIONADJ LEGAL DOCS PETITION TO COMPEL DEPOSITIONADJ LEGAL DOCS PETITION TO COMPEL DEPOSITION - WALKTHROUGHADJ LEGAL DOCS PETITION TO COMPEL DEPOSITION - WALKTHROUGHADJ LEGAL DOCS PETITION TO DISMISS APPLICANTADJ LEGAL DOCS PETITION TO DISMISS APPLICANTADJ LEGAL DOCS PETITION TO DISMISS ATTORNEYADJ LEGAL DOCS PETITION TO DISMISS ATTORNEYADJ LEGAL DOCS PETITION TO DISMISS PARTY DEFENDANTADJ LEGAL DOCS PETITION TO DISQUALIFY PANEL QMEADJ LEGAL DOCS PETITION TO ENFORCEADJ LEGAL DOCS PETITION TO ENFORCE IBR DETERMINATIONADJ LEGAL DOCS PETITION TO JOIN DEFENDANTADJ LEGAL DOCS PETITION TO JOIN APPLICANTADJ LEGAL DOCS PETITION TO JOIN UEBTF

Document Titles List (Rev. 4/2014) updated 7/29/2014 4

ADJ LEGAL DOCS PETITION TO QUASH DEPOSITIONADJ LEGAL DOCS PETITION TO QUASH SUBPOENA

Product Delivery Document type Document TitleADJ LEGAL DOCS PETITION TO REOPENADJ LEGAL DOCS PETITION TO REOPEN TO REDUCEADJ LEGAL DOCS PETITION TO RESOLVE MED-LEGAL DISPUTE-NON IBR ADJ LEGAL DOCS PETITION TO SEAL THE RECORDADJ LEGAL DOCS PETITION TO SET ASIDE COMPROMISE AND RELEASEADJ LEGAL DOCS PETITION TO SET ASIDE STIPULATIONSADJ LEGAL DOCS PETITION TO STRIKE RATING INSTRUCTIONSADJ LEGAL DOCS PETITION TO SUSPEND PROCEEDINGS

ADJ LEGAL DOCS PETITION TO TERMINATE LIABILITY FOR MEDICAL TREATMENT

ADJ LEGAL DOCSPETITION TO TERMINATE LIABILITY FOR TEMPORARY DISABILITY INDEMNITY

ADJ LEGAL DOCS PETITION TO TRANSFER CARE TO MEDICAL PROVIDER NETWORKADJ LEGAL DOCS PETITION TO UNSEAL THE RECORDADJ LEGAL DOCS PETITION TO VACATE SUBMISSIONADJ LEGAL DOCS POINTS AND AUTHORITIESADJ LEGAL DOCS POINTS AND AUTHORITIES-TRIAL BRIEF-HEARING BRIEFADJ LEGAL DOCS PRE-TRIAL CONFERENCE STATEMENT (5 PAGER)ADJ LEGAL DOCS PROOF OF SERVICEADJ LEGAL DOCS PROPOSED ORDER/AWARDADJ LEGAL DOCS QME WAIVERADJ LEGAL DOCS REQUEST FOR CONTINUANCEADJ LEGAL DOCS REQUEST FOR ORDER TAKING OFF CALENDARADJ LEGAL DOCS REQUEST TO WITHDRAW PETITION FOR RECONSIDERATIONADJ LEGAL DOCS REQUEST TO WITHDRAW PETITION FOR REMOVALADJ LEGAL DOCS RESPONSE TO PETITION ADJ LEGAL DOCS RESUBMITTED 1990 APPLICATIONADJ LEGAL DOCS SPECIAL NOTICE OF LAWSUITADJ LEGAL DOCS STIPS: RESPONSE TO LETTER REQUESTING INFORMATIONADJ LEGAL DOCS STIPULATION AND AWARD AND/OR ORDER

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ADJ LEGAL DOCS STIPULATION WITH AWARD(DEATH)ADJ LEGAL DOCS STIPULATIONS WITH REQUEST FOR AWARD

ADJ LEGAL DOCS STIPULATIONS WITH REQUEST FOR AWARD - WALK-THROUGHADJ LEGAL DOCS STIPULATIONS WITH REQUEST FOR AWARD POST 1-1-2013

Product Delivery Document type Document Title

ADJ LEGAL DOCSSTIPULATIONS WITH REQUEST FOR AWARD- WALK-THROUGH POST 1-1-2013

ADJ LEGAL DOCS SUBSTITUTION OF ATTORNEYADJ LEGAL DOCS SUPPLEMENTAL PETITION FOR RECONSIDERATIONADJ LEGAL DOCS THIRD PARTY COMPROMISE AND RELEASEADJ LEGAL DOCS TRANSCRIPT OF RECORDADJ LEGAL DOCS VENUE VERIFICATIONADJ LEGAL DOCS WAGE STATEMENTADJ LEGAL DOCS WITHDRAWAL OF DECLARATION OF READINESS TO PROCEEDADJ LEGAL DOCS WRITADJ LIENS AND BILLS 4903.8 ASSIGNMENTADJ LIENS AND BILLS 4903.8 DECLARATIONADJ LIENS AND BILLS BILLS-OTHERADJ LIENS AND BILLS CONFIRMATION OF LIEN FILING FEEADJ LIENS AND BILLS EDD LIENADJ LIENS AND BILLS MEDICAL BILLSADJ LIENS AND BILLS NOTICE AND REQUEST FOR ALLOWANCE OF LIENADJ LIENS AND BILLS REQUEST FOR WITHDRAWAL OF LIENADJ MEDICAL DOCS ALL MEDICAL REPORTSADJ MEDICAL DOCS AME REPORTSADJ MEDICAL DOCS P & S REPORTADJ MEDICAL DOCS QME REPORTSADJ MEDICAL DOCS TREATING PHYSICIANADJ MISC CONSULTATIVE RATINGADJ MISC CORRESPONDENCE – OTHERADJ MISC SETTLEMENT OFFER LETTERADJ MISC SUBPOENAADJ MISC SUBPOENA DUCES TECUM

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ADJ MISC SUMMARY RATINGADJ MISC TRANSMITTAL LETTERADJ MISC TYPED OR WRITTEN LETTER

DEU DEU DOCS - OTHER EARNINGS INFORMATION

DEU DEU DOCS - OTHER JOB DESCRIPTION

Product Delivery Document type Document Title

DEU DEU DOCS - OTHER PHOTOGRAPHS

DEU DEU DOCS - OTHER RESPONSE TO REQUEST FOR FACTUAL CORRECTIONDEU DEU FORMS COMMUTATION REQUESTDEU DEU FORMS EMPLOYEES PERMANENT DISABILITY QUESTIONAIREDEU DEU FORMS REQUEST FOR CONSULTATIVE RATINGDEU DEU FORMS REQUEST FOR FACTUAL CORRECTION

DEU DEU FORMSREQUEST FOR INFORMAL RATING BY INSURANCE CARRIER OR SELF-INSURER

DEU DEU FORMS REQUEST FOR RECONSIDERATION OF SUMMARY RATING BY THE AD

DEU DEU FORMS REQUEST FOR SUMMARY RATING DETERMINATION - QME REPORT

DEU DEU FORMSREQUEST FOR SUMMARY RATING DETERMINATION – TREATING PHYSICIAN

DEU MEDICAL REPORTS AME

DEU MEDICAL REPORTS DEFAULT QME (REPRESENTED WITH DOI ON/AFTER 1-1-05)

DEU MEDICAL REPORTS PANEL QME (NON-REPRESENTED ALL DOI)

DEU MEDICAL REPORTS REPRESENTED QME (REPRESENTED WITH DOI BEFORE 1-1-05)

DEU MEDICAL REPORTS TREATING PHYSICIAN

DEU MISC PROOF OF SERVICE

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DEU MISC TYPED OR WRITTEN LETTERINT AD LEGAL MEDICAL REPORTSINT AD LEGAL MISCELLANEOUSINT AD LEGAL PETITION FOR CHANGE OF PRIMARY TREATING PHYSICIAN

INT AD LEGALRESPONSE TO PETITION FOR CHANGE OF PRIMARY TREATING PHYSICIAN

INT MEDICAL DOCS MEDICAL REPORTS

INT MEDICAL DOCS REQUESTS TO I&A FOR REPLACEMENT OR ADDITIONAL QME PANELINT MISC CORRESPONDENCEINT MISC GENERAL PUBLIC REQUEST FOR INFORMATIONINT MISC I & A CONFERENCE APPOINTMENT NOTICEINT MISC REQUEST TO I & A FOR CONFERENCERSU DWC - AD FORMS DWC-AD 10118 NOTICE OF OFFER OF REGULAR WORK

Product Delivery Document type Document Title

RSU DWC - AD FORMSDWC-AD 10133.32 SUPPLEMENTAL JOB DISPLACEMENT NON-TRANSFERABLE VOUCHER

RSU DWC - AD FORMS DWC-AD 10133.33 DESCRIPTION OF EMPLOYEE'S JOB DUTIES

RSU DWC - AD FORMSDWC-AD 10133.35 NOTICE OF OFFER OF REG MOD OR ALTERNATIVE WORK

RSU DWC - AD FORMSDWC-AD 10133.36 PHYSICIAN’S RETURN-TO-WORK & VOUCHER REPORT

RSU DWC - AD FORMSDWC-AD 10133.53 NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK

RSU DWC - AD FORMS DWC-AD 10133.57 SUPPLEMENTAL JOB DISPLACEMENT VOUCHER

RSU DWC - AD FORMS DWC-AD-10133.55 REQUEST FOR DISPUTE RESOLUTION BEFORE THE AD RSU DWC - AD FORMS OBJECTION - OTHER

RSUNON-FORM

CORRESPONDENCE LETTERRSU OTHER OTHER CORRESPONDENCERSU OTHER PROOF OF SERVICE

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RSUSUPPORTING DOCUMENTS ERGONOMIC REPORT

RSUSUPPORTING DOCUMENTS JOB DESCRIPTION

RSUSUPPORTING DOCUMENTS MEDICAL REPORT

RSUSUPPORTING DOCUMENTS POSITION STATEMENT

RSUSUPPORTING DOCUMENTS SCHOOL & VRTWC INVOICES

RSUSUPPORTING DOCUMENTS VRTWC REPORT

*Use this document to determine the proper document title used to complete the document separator sheet

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