Workers’ Compensation Documents

Title Link to File
R3 Event Table R3eventtable (1).xls
R3 Edit Matrix EDI_R3_EditMatrix (1).xls
Proof of Coverage pocguide.pdf
Present Value Discount Table presentvaluediscounttable.xls
Preference for Sixth Edition of the AMA Guides serslandreport.pdf
Payment Activity Report 14-0147 14-0147par.pdf
Partial Commutation 14-0017 14-0017-PartCommPgs1-2.pdf
Original Notice: Vocational Rehabilitation Program Benefit 14-0009 14-0009.pdf
Original Notice: Independent Medical Examination 14-0007 14-0007imefillable.pdf
Original Notice: Application for Alternate Medical Care (85.27) 14-0011 14-0011altcarefillable.pdf
Original Notice and Petition Form No. 100 (Fillable) 14-0005 form100fillable.pdf
Original Notice and Petition Form No. 100 14-0005 14-0005 form100fillable.pdf
Original Notice & Petition for Partial Commutation — Form 9A (14-0017) Partial Commutation -- Original Notice & Petition -- Form 9A - 14-0017 --July 2019.pdf
Original Notice & Petition for Full Commutation of All Remaining Benefits of 10 Weeks or More — Form 9 (14-0013) Full Commutation -- Original Notice & Petition -- Form 9 - 14-0013 -- July 2019.pdf
Original Notice & Petition Concerning Vocational Rehabilitation Program Benefit — Form 100B (14-0009) Vocational Rehabilitation Program Benefit -- Form 100B - 14-0009 -- July 2019.pdf
Original Notice & Petition Concerning Independent Medical Examination — Form 100A (140007) Independent Medical Exam -- Original Notice & Petition -- Form 100A - 14-0007 -- July 2019.pdf
Original Notice & Petition Concerning Application for Alternate Care -- Form 100C (14-0011) Alternate Care -- Original Notice & Petition -- Form 100C - 14-0011 -- July 2019.pdf
Order: In the Matter of Change in Location for Hearings Held in Davenport Order -- Change in Location for Hearings Held in Davenport -- July 30, 2019.pdf
Order: In the Matter of What Date Stamp Governs for Documents Paper-Filed With the Agency From July 1, 2019, Through July 19, 2019, and Subsequently Electronically Filed by Agency Staff Order -- What Date Stamp Governs for Docs Paper-Filed From July 1 through July 19, 2019 -- Aug. 2, 2019.pdf
Order Form for Iowa EDI Release 2 Implementation Guide ediorderform.pdf
Nonelection of Coverage Form 14-0175nonelection.pdf
New R3.1 Implementation Guide, Transition Timeline Summary and Test Plan Now Available Iowa EDI R3.1 Updates Claims Implementation Guide and Information V1.0 (4-9-18) (1).pdf
Member Report Regarding the AMA Guides, Sixth Edition by John Kuhnlein, D.O. kuhnleinreport.pdf
Medical Report Transmittal Form 14-0141 14-0141medtransmit.pdf
Mark D. Sloan v Mark D. Sloan, D.D.S., P.C., d/b/a Sloan Family Dentistry, P.C. SLOAN,MARK D. Partial Commutation Ruling.pdf