Dwc request 2025

1. Click ‘Get Form’ to open the dwc request in the editor.
2. Begin by filling out the Employee Information section. Enter the employee's name, date of birth, claim number, date of injury, and employer name accurately.
3. Next, complete the Provider Information section. Input your name, contact details, address, phone number, fax number, email address, and NPI number.
4. In the Claims Administrator Information section, provide the claims administrator's name and contact information as required.
5. For Bill Information, include any identification numbers and dates related to previous reviews. List all disputed services or goods along with their respective amounts and authorization status.
6. Attach any supporting documentation that may assist in your request for a second bill review.
7. Finally, ensure you sign and date the form at the bottom before submitting it via mail or fax to the claims administrator.

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