USEFUL FORMS & LINKS

Retainer Agreement - SU LAW, APC

DWC-1 Claim Form

Fee Disclosure Statement

Labor Code Section 4906(h) Declaration

Venue Verification

Gemini Duplication Authorization

Kaiser Permanente Authorization

VA Authorization

Consent For Release Of Information - SSA

Consent to Release Form - CMS

Request for Qualified Medical Evaluator Panel (Unrepresented Employee)

Substitution of Attorneys (Use This Form If You Want to Dismiss Your Attorney)

Medical Mileage Reimbursement Forms:

Mileage For Travel On Or After 01/01/2023

Mileage For Travel On Or After 07/01/2022

Mileage For Travel On Or After 01/01/2022

Mileage For Travel On Or After 01/01/2021

Mileage For Travel On Or After 01/01/2020

Supplemental Job Displacement Voucher:

SJDB Voucher FAQ

SJDB Voucher (Sample)

Apply For One-Time $5,000 Payment From RTWSP (Return-To-Work Supplement Program) (Requires SJDB Voucher For Injury After 01/01/2013)

How Social Security & Medicare Affect Your Workers’ Compensation Case:

How Workers’ Compensation And Other Disability Payments May Affect Your Social Security Benefits

Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide Version 3.8 11/14/2022

Criteria For Determining Whether A MSA Is Adequate

Medicare Secondary Payer Recovery Process