DWC Lien Form

The California Division of Workers’ Compensation (DWC), along with the Workers’ Compensation Appeals Board (WCAB), has released an amended lien form including the new declaration requirements set forth by Labor Code Section 4903.05(c). All liens filed after January 1, 2017, must use this form.

Frequently Asked Questions:

Q: What happens when you treat an applicant on a lien basis. Can you still file a lien?

A: In order to file the lien, you must have documented evidence that the employer neglected or unreasonably refused the necessary treatment to the injured employee.

Q: Do I need to take any steps if I filed a lien prior to January 1?

A: Yes. Existings lien filed prior to January 1, 2017 must file a supplemental lien declaration form by July 1, 2017. The form is included below.

Q: Is anything else about the filing process changing?
Yes. As of January 1, you must always submit an original bill with your lien.

Q: Why all the lien reform?

A: In part, to crack down on fraud.

Q: Do you have a resource I can use to learn more about lien reform?
Absolutely. We devoted two webinars to the o lien reform in SB 1160:


SB 1160 amended Labor Code 4903.05 to require all medical treatment and med-legal lien claimants to file a new mandated lien declaration starting on January 1, 2017. The declaration must:

  1. Affirm that the lien is not a dispute subject to Independent Medical Review (IMR) or Independent Bill Review (IBR), and
  2. Must also affirm that the claimant satisfies at least one of seven new lien claimant requirements:

(A) Is the employee’s treating physician providing care through a medical provider network.

(B) Is the agreed medical evaluator or qualified medical evaluator.

(C) Has provided treatment authorized by the employer or claims administrator under Section 4610.

(D) Has made a diligent search and determined that the employer does not have a medical provider network in place.

(E) Has documentation that medical treatment has been neglected or unreasonably refused to the employee as provided by Section 4600.

(F) Can show that the expense was incurred for an emergency medical condition, as defined by subdivision (b) of Section 1317.1 of the Health and Safety Code.

(G) Is a certified interpreter rendering services during a medical-legal examination, a copy service providing medical-legal services, or has an expense allowed as a lien under rules adopted by the administrative director.


Existing liens are also subject to new declaration requirements. For liens filed prior to January 1st, 2017, existing holders must file a declaration retroactively affirming that the lien claimant satisfies one or more of the seven new requirements listed above. These declarations are due on or before July 1st, 2017.

Liens filed without the declaration will be dismissed. What’s more, the dismissal will be made “with prejudice by operation of law,” meaning that no other lien can be filed, nor can the applicant seek further payment in any other way. The dismissal happens automatically after the deadline to file passes with no lien declaration.

As of January 1, Section 4903.05 of the Labor Code requires that lien claimants must also submit an original bill with their lien.

Download the New Supplemental Lien Form

DaisyBill is working to acquire the new lien form, to be used for all liens filed after January 1, 2017. Copies of the form should be available to e-Filers or JET filers through the filing system.

Supplemental Lien Declaration Form

Use this declaration form for all liens filed prior to January 1, 2017, that require a filing fee under the newly-amended Labor Code Section 4903.05. The declaration must be filed prior to July 1, 2017. The file above automatically downloads when you click the link. Problems? Contact us so we can help.

Additional Information

Full text of SB 1160

DaisyBill Resources

Webinar: Senate Bills 1160 and 1175

Webinar: The New Lien Declaration


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