California Audit Form PDF Details

Within the framework of ensuring justice and adherence to regulatory standards in California's workers' compensation system, the California Audit Complaint Form serves as a critical instrument for addressing grievances. This form allows individuals to report discrepancies or non-compliance by claims administrators, operating under the umbrella of the Department of Industrial Relations, Division of Workers’ Compensation (DWC). Key to this process is the form's dual functionality; it not only facilitates the monitoring of claims administrators by the DWC but also supports the collaboration between DWC and other governmental entities in enforcing civil and criminal laws. Importantly, the form provides an option to maintain the confidentiality of the complainant, a provision that underscores the state's commitment to protecting personal information. Moreover, the form is designed to gather comprehensive details about the complaint, including specifics about late payments, failures in medical treatment payments, investigation lapses, or any unsupported claim denials, thus ensuring a thorough review process. Its design recognizes the importance of supporting documentation, enhancing the validity and strength of the complaint. Not to be overlooked is the form’s recognition of privacy concerns; it aligns with the Public Records Act to safeguard sensitive information from public disclosure, reinforcing the rights and privacy of the injured worker. This form, therefore, is not merely an administrative tool; it is a testament to California’s proactive stance on oversight and accountability within the workers’ compensation arena.

QuestionAnswer
Form NameCalifornia Audit Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesca 906 form, audit referral, california audit form, au906

Form Preview Example

AUDIT COMPLAINT FORM

IF YOU WANT THIS COMPLAINT TO BE KEPT CONFIDENTIAL, PLEASE MARK THIS BOX:

DIR PRIVACY NOTICE: The Department of Industrial Relations, Division of Workers’ Compensation uses the information in your complaint (1) to monitor workers’ compensation claims administrators; (2) to assist DWC and other government agencies in general civil and criminal law enforcement; and (3) to conduct research on the workers’ compensation system. If you indicate that you want your complaint kept confidential, the Audit Unit will not share your complaint with any party named in your complaint. If you do not request confidentiality, the Audit Unit may share your complaint with the claims administrator. Please note that your complaint and your workers’ compensation claim information cannot be disclosed to the public under the Public Records Act. If you have questions about this notice please write to Privacy@dir.ca.gov.

Claims administrator / Company name

Claims administrator’s address

Injured worker name

Claim number

City, state, zip (physical location only- do not use P.O. Box) Date of injury

Date or period of violations

Employer

SPECIFIC DETAILS OF COMPLAINT

Describe the nature of the complaint, being as specific as possible. For example, late payments of temporary or permanent disability (the number of late payments, if known), failure to pay temporary or permanent disability, or 10% self- imposed penalties for late payments (indicate the periods not paid, if known), failure to pay or object to medical treatment or medical-legal bills, failure to investigate a claim, unsupported denial of liability for a claim, et al. Please attach copies of supporting documentation, if available.

Complainant (name & title)

Date

Address, city, state, zip code

Email: ______________________

 

DWC-AU-906 (Rev. 05/21)

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