NMWCA Forms

Instructions for downloading:

1. The sections are separated by categories and forms that pertain to that section are listed in the boxes.
2. When you locate the form you need, click on the icon for the specific format to download the form.
3. The formats are document for Microsoft Word, Excel for Microsoft Excel, or pdf for Adobe PDF.

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Legal Forms - Mandatory

Please the select the form and click on the link to download.

Mandatory Forms (A-R)

Application to Director  document  pdf
Application to Workers' Compensation Judge   document  pdf
Petition for Lump Sum Payment  document  pdf
Health Care Provider (HCP) Disagreement Form  document  pdf
Joint Request for Expedited Section 52-5-12 Hearing  document  pdf
Notice of Acceptance or Rejection of Recommended Resolution  document  pdf  
Request for Setting  document  pdf
Informal Response document  pdf

Mandatory Forms (S-Z)

Subpoena  document  pdf
Summons for Application to Director   document  pdf
Summons for Application to Workers' Compensation Judge  document pdf
Summons for Petition for Lump Sum Payment  document  pdf
Summons for Workers' Compensation Complaint  document  pdf
Worker's Authorization for Use and Disclosure of Health Records (HIPAA)   document  pdf
Worker's Compensation Complaint  document  pdf

Legal Forms - Optional

Please the select the form and click on the link to download.

Optional Forms (A-R)

Change of Address document  pdf
Form Letter to Health Care Provider  document  pdf
Joint Waiver of Disqualification  document  pdf 

Optional Forms (S-Z)

Notice of Change of Health Care Provider  document  pdf  
Notice of Disqualification  document  pdf 
Out of State Health Care Provider Affidavit/Order Granting Approval  document  pdf
Worker's Response  document  pdf

Legal Forms - Packets

Notice: Forms found in packets are put together so that filers know what forms are needed. Despite forms being together in a packet, when e-filing, forms must be filed individually.

Please the select the form and click on the link to download.

Packets

Application to Director Packet  pdf
Application to Workers' Compensation Judge Packet  pdf
Lump Sum Payment Packet  pdf
Out of State Health Care Provider Packet  pdf
Workers' Compensation Complaint Form Packet  pdf
Uninsured Employers Packet pdf

Miscellaneous Forms

Affidavit of Annual Safety Inspection  document  pdf 
Average Weekly Wage  pdf
Notice of Accident   pdf
Report Fraud   pdf
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Insurance Forms

Please the select the form and click on the link to download.

Coverage

Election to be Subject  pdf
Executive Employee Affirmative Election  pdf  
Revocation of Prior Election   pdf
 
 

Self-Insurance

Amendatory Endorsement  document
Application - Individual  document 
Application - Group  document 
Board of Directors Resolution  document  
Letter of Credit - Individual  document 
Letter of Credit - Group  document
Surety Bond - Individual  document
Surety Bond - Group  document
Parental Guaranty for subsidiaries  document 

Data Reporting

Please the select the form and click on the link to download.

Reporting Forms

Inpatient Medical Data: E9   pdf
EDI Trading Partner Profile: E7   pdf
Proof of Coverage Profile: E8   pdf
Inpatient Data Supplement: E10-1   pdf 

Medical Forms

Approval of Out of State HCP Letter  document  pdf
Medical Service Referral  pdf   
Provider's Report of Physical Ability (PROPA)    pdf
Release for Health Care Records (HIPAA)  document  pdf
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