Division of Coal Mine Workers' Compensation

Claim Forms & Instructions

Administrative Forms & Links

Claimant Medical Reimbursement (OWCP-915)

Medical Travel Refund Request (OWCP-957)

Health Insurance Claim Form (OWCP-1500) | (Instructions)

Uniform Health Insurance Claim Form (OWCP-04) | (Instructions)

Certificate of Medical Necessity (CM-893)

How to Submit a Paper Pharmacy Bill

DCMWC Pharmacy Payer Sheet

Provider Enrollment Application:Downloadable Form

Provider Enrollment Training Presentation:

How to Complete a Provider Enrollment Application Tutorial (Individual)
How to Complete a Provider Enrollment Application Tutorial (Facility)
How to Complete a Provider Enrollment Application Tutorial (Group)
How to Complete an ACH Vendor Payment Form Tutorial

To order Pharmacy Universal Claim Forms, please call Moore-Wallace North America at (800) 635-9500. For more information you may view the NCPDP site.

P2P EDI Information

Conduent EDI Gateway Information

To enroll with EDI, please complete this document: EDI Enrollment Form

EFT Form | (Instructions)

Provider Change of Address

DCMWC Form Information

DCMWC Program: Q & A

Oxygen Reimbursement Revision

Physicians & Pharmacy Info Re: Oxycontin

Program District & Offices