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TDI Forms

This is one of several pages linking to a central repository of forms used by TDI customers. Use the search or Forms by Type links on the Forms Home Page or scan through our form listings.

Life, Health & Licensing - Workers' Compensation Health Care Networks Forms
TDI Form Number Description File Format
FIN306 Officers and Directors Page
Compliance with statutes		 PDF
FIN312 Attorney for Service
Compliance with statutes		 PDF
Life, Health & Licensing - Workers' Compensation Health Care Networks Forms
TDI Form Number Description File Format
LHL390 WC Network Biographical Affidavit Form
Workers' Compensation Health Care Network Biographical Affidavit		 PDF
LHL390 WC Network Biographical Affidavit Form
Workers' Compensation Health Care Network Biographical Affidavit		 WORD
LHL391 WC Network Application Form
Workers' Compensation Health Care Network Application		 PDF
LHL391 WC Network Application Form
Workers' Compensation Health Care Network Application		 WORD
LHL392 WC Network Application Certification Requirements Checklist
Workers' Compensation Health Care Network Application Certification Requirements Checklist		 PDF
Life, Health & Licensing - Workers' Compensation Health Care Networks Forms
TDI Form Number Description File Format
FIN141 Authorization Release Form
For a Company to authorize financial institutions to release their bank and securities information to TDI.		 WORD
FIN141 Authorization Release Form
For a Company to authorize financial institutions to release their bank and securities information to TDI. 		PDF
Additional Workers' Compensation Health Care Networks Forms
TDI Form Number Description File Format
  Workers' Compensation Complaint Form HTML
  QI Plan Report
Sample Quality Improvement Report Formats 		WORD
  Employee Acknowledgment Form Samples HTML
  Sample Injured Worker Survey Instrument WORD
  Sample Contingency Plan for Delegated Functions form WORD

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For more information contact: WCNET@tdi.state.tx.us



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