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Injured Worker Information IMC-12203A - California
| Injured Worker Information Form. This is a California form and can be used in General Workers Comp . |
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STATE OF CALIFORNIA Arnold Schwarzenegger, Governor DEPARTMENT OF INDUSTRIAL RELATIONS Industrial Medical Council DWC - Medical Unit P.O. Box 420603 San Francisco, CA 94142 INJURED WORKER INFORMATION Panel #: Date of Request: Claim No.: Claims Administrator: To: Date of Issue: Date of Injury: SELECTED QUALIFIED MEDICAL EVALUATOR PANEL: PHYSICIAN'S NAME ADDRESS Tel. No.: SPECIALTY YEARS IN PRACTICE PHYSICIAN'S EDUCATION PHYSICIAN'S TRAINING PHYSICIAN'S NAME ADDRESS Tel. No.: SPECIALTY YEARS IN PRACTICE PHYSICIAN'S EDUCATION PHYSICIAN'S TRAINING PHYSICIAN'S NAME ADDRESS Tel. No.: SPECIALTY YEARS IN PRACTICE PHYSICIAN'S EDUCATION PHYSICIAN'S TRAINING IMC FORM 12203A (rev. 2/96) Authority cited: Sections 139.2, 4061, 4062, Labor Code. Reference: Section 139.2, Labor Code. American LegalNet, Inc. www.USCourtForms.com
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