DWC Form 5021Doctor's First Report of Occupational Injury or Illness

Clinicians fill out · Submitted to regulator · Employers file

When it’s used

Initial examination (Form 5021 within 5 working days); significant change in condition; change in treatment plan (extension of duration/frequency, new hospitalization/surgery, new referral/consultation, change in methods, new DME/orthotics); employee able to return to modified or regular work; change in work restrictions; release from care; permanent disability precludes usual occupation; claims administrator request for information; every 45 days during continuing treatment even if no triggering event (8 CCR §9785(f))

Who fills it out

Treating physician of record. NPs and PAs are not included in the definition of 'physician' under Labor Code §3209.3 and cannot serve as the primary treating physician (PTP). Only MDs, DOs, psychologists, acupuncturists, optometrists, dentists, podiatrists, and chiropractors qualify. NPs/PAs may provide treatment under supervising physician but the PTP must sign reports.

Who signs

NPs and PAs are not included in the definition of 'physician' under Labor Code §3209.3 and cannot serve as the primary treating physician (PTP). Only MDs, DOs, psychologists, acupuncturists, optometrists, dentists, podiatrists, and chiropractors qualify. NPs/PAs may provide treatment under supervising physician but the PTP must sign reports.

Where it goes

Form 5021: within 5 working days of initial examination; PR-2: within 20 days of triggering event; continuing treatment PR-2: no later than 45 days from last report of any type; P&S report (PR-3/PR-4): within 20 days of examination (8 CCR §9785)

Electronic submission

Supported — Reports may be transmitted by mail, fax, or any other means satisfactory to the claims administrator, including electronic transmission (8 CCR §9785(d)). No centralized state portal; submission goes directly to the claims administrator.

Narrative substitution

Narrative report may substitute for Form PR-2, but must be entitled 'Primary Treating Physician's Progress Report' in bold, must contain the same information using the same subject headings in the same order as Form PR-2, and must include the statutory declaration under penalty of perjury (8 CCR §9785(f)). Form 5021 has no narrative substitute.