NMWCA Forms

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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 (Effective 10/1/15)  document  pdf
Application to Workers' Compensation Judge (Revised 10/1/15)  document  pdf
Combined Petition for Lump Sum Payment (Effective 4/1/16)  document  pdf
Health Care Provider (HCP) Disagreement Form  document  pdf
Notice of Acceptance or Rejection of Recommended Resolution  document  pdf
Notice of Disqualification  document  pdf
Notice of Hearing  document  pdf
Request for Setting  document  pdf
Response document  pdf

Mandatory Forms (S-Z)

Subpoena  document  pdf
Summons for Application to Director (Effective 10/1/15)  document  pdf
Summons for Application to Workers' Compensation Judge (Revised 10/1/15)  document pdf
Summons for Petition for Lump Sum Payment (Effective 10/1/15)  document  pdf
Summons for Workers' Compensation Complaint  document  pdf
Worker's Authorization for Use and Disclosure of Health Records (Revised 7/26/16)  document  pdf
Worker's Compensation Complaint (Revised 10/1/15)  document  pdf

Legal Forms - Optional

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Optional Forms (A-R)

Form Letter to Health Care Provider  document  pdf
Health Care Provider Selection Letter - Employer/Insurer Choice  document  pdf
Health Care Provider Selection Letter - Worker Choice  document  pdf
Joint Request for Expedited Section 52-5-12 Hearing  document  pdf
Joint Waiver of Disqualification  document  pdf
Joint Waiver of Service of Process  document  pdf
Joint Waiver of Disqualification and Waiver of Service of Process  document  pdf

Optional Forms (S-Z)

Notice of Change of Health Care Provider  document  pdf  
Objection to Notice of Change of Health Care Provider  document  pdf
Out of State Health Care Provider Affidavit and Order Granting Approval (Revised 10/1/15)  document  pdf

Legal Forms - Packets

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Packets

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

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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

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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  
Motion for Out of State HCP  document  pdf
Release for Health Care Records (HIPAA)  document  pdf
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