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DCMWC Forms
OWCP’s Division of Coal Mine Workers' Compensation has made a variety of forms available online. These forms are only available in PDF format. In order to view and/or print PDF documents you must have a PDF viewer. It is highly recommended that you have the most current version (click on Adobe Acrobat Reader to download the current version) available on your workstation.
The forms in the list below may be completed manually via the print form option or electronically via the electronic fill/submit option:
Print Form Option
Most of DCMWC’s forms are available online to print and to manually fill and submit. Simply click on the appropriate form and print it using the [Print] button provided near the top of the form. Write or type the required information on the hardcopy and authorize the form, if applicable, with a hand-written signature. Then mail the completed form to the DCMWC office you normally send to for this process.
Form-Fill Option
Simply click on the appropriate form, fill out the form using your computer keyboard and the <TAB> key or your mouse to navigate between form fields. Print the form (use the Print button on or near the top of the form), authorize the form (if applicable provide hand-written signature) and mail the completed form to the DCMWC office you normally send to for this process.
Electronic Fill/Submit Option
Select DCMWC forms, noted with an asterisk (*) on the list of forms below, may be electronically filled and submitted to OWCP/DCMWC. To do so, you must have Adobe Reader 6.x installed on your PC.
To electronically submit a DCMWC form, follow these simple steps:
- Obtain an electronic signature from IdenTrust Inc. Upon opening the form, if you don't already have a digital signature on your PC, you will be directed to the IdenTrust Inc. website to obtain an electronic signature. The entire process of obtaining the electronic signature will take 5-10 business days. (You only have to do this one time. Thereafter, you will use the same signature.) Note: Adobe 6.x is required to apply a digital signature
- Fill out the form completely. It is recommended that you print the form prior to submitting, and keep the hardcopy for your records. To do so, use the [Print] button provided near the top of the form.
- Click on the [Submit] button near the top of the form. A message will appear noting that the form has been received and will provide an identification number. It is recommended that you record the ID number on your hardcopy.
- If you have questions about filling/submitting these forms or need other forms assistance, you can send DCMWC a question via e-mail. DCMWC will respond to your question via e-mail.
NOTE: When printing these files please remember to use the Adobe Acrobat Reader print icon or the [Print] button on the form, itself, and NOT your browser's print icon on the browser toolbar.
Black Lung Forms
CM-623, |
Representative Payee Report |
CM-623S, |
Representative Payee Report |
CM-787, |
Physician's/Medical Officer's Statement |
CM-893, |
Certificate of Medical Necessity |
CM-908, |
Notice of Termination, Suspension, Reduction or Increase in Benefit Payments |
CM-910, |
Request To Be Selected As Payee |
CM-911, |
Miner's Claim For Benefits Under The Black Lung Benefits Act |
CM-911a, |
Employment History |
CM-912, |
Survivor's Form For Benefits Under The Black Lung Benefits Act |
CM-913*, |
Description Of Coal Mine Work and Other Employment
On-line submission now available
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CM-921, |
Instructions For Completion of Form CM-921 |
CM-929, |
Report of Changes That May Affect Your Black Lung Benefits |
CM-929P, |
Report of Changes That May Affect Your Black Lung Benefits |
CM-933, |
Roentgenographic Interpretation |
CM-933b, |
Roentgenographic Quality Rereading |
CM-936*, |
Authorization For Release Of Medical Information (Black Lung Benefits)
On-line submission now available
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CM-972, |
Application for Approval of a Representative's Fee in a Black Lung Claim Proceeding Conducted by The U.S. Department of Labor |
CM-981*, |
Certification by School Official
On-line submission now available
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CM-988, |
Medical History and Examination for Coal Mine Workers' Pneumoconiosis |
CM-1159, |
Report of Arterial Blood Gas Study |
CM-2907, |
Report of Ventilatory Study |
CM-2970*, |
Operator Response to Schedule for Submission of Additional Evidence
On-line submission now available
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CM-2970a*, |
Operator Response to Notice of Claim
On-line submission now available
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OWCP-1, |
Agreement and Undertaking |
OWCP-915, |
Claim For Medical Reimbursement
Form OWCP-915 replaces CA-915
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OWCP-957, |
Medical Travel Refund Request |
OWCP-1168, |
Provider Enrollment Form |
OWCP-1500, |
Health Insurance Claim Form |
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