Texas > Workers Compensation > Carrier
Request For Designated Doctor Examination DWC-32 - Texas
| Request For Designated Doctor Examination Form. This is a Texas form and can be used in Carrier Workers Compensation . |
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DWC032 Texas Department of Insurance Division of Workers' Compensation 7551 Metro Center Drive, Suite 100 · MS-603 Austin, TX 78744-1645 (512) 804-4380 phone · (512) 804-4121 fax Complete, if known: DWC Claim # Carrier Claim # Request for Designated Doctor Examination Type (or print in black ink) each item on this form I. INJURED EMPLOYEE INFORMATION 1. Employee Name (First, Middle, Last) 3. Employee Address (Street or P.O. Box, City, State, Zip Code) 5. Employee Primary Phone Number ( ) 7. Employee Date of Birth (mm-dd-yyyy) II. EMPLOYER INFORMATION (at the time of injury) 9. Employer Name 11. Employer Address (Street or P.O. Box, City, State, Zip Code) III. INSURANCE CARRIER INFORMATION 12. Insurance Carrier Name 13. Insurance Carrier Address (Street or P.O. Box, City, State, Zip Code) 14. Adjuster Name (First, Middle, Last) 16. Adjuster Phone Number ( ) 18. Insurance Carrier's Authorized Agent Company Name 19. Insurance Carrier's Bill Review Agent Name 20. Bill Review Agent Address (Street or P.O. Box, City, State, Zip Code) 21. Bill Review Agent Phone Number ( ) 2. Employee Social Security Number 4. Employee County 6. Employee Alternate Phone Number ( ) 8. Date of Injury (mm-dd-yyyy) 10. Employer Phone Number ( ) 15. Adjuster E-mail Address 17. Adjuster Fax Number ( ) Only Insurance Carriers Complete Boxes 18 - 22 22. Bill Review Agent Fax Number ( ) 24. Representative's Phone Number ( ) 26. Representative's Fax Number ( ) For TDI-DWC Use Only IV. INJURED EMPLOYEE REPRESENTATIVE INFORMATION (if any) 23. Representative's Name (First, Middle, Last) 25. Representative's E-mail Address DWC032 Rev. 01/13 American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 7 DWC032 V. TREATING DOCTOR INFORMATION 27. Treating Doctor Name 29. Treating Doctor Address (Street or P.O. Box, City, State, Zip Code) 31. Treating Doctor License Number 28. Treating Doctor Phone Number ( ) 30. Treating Doctor Fax Number ( ) 32.Treating Doctor License Type VI. DESIGNATED DOCTOR SELECTION INFORMATION 33. Does the claim involve medical benefits provided through a Certified Workers' Compensation Health Care Network? Yes No If yes, provide the name of the network. 34. Does the claim involve medical benefits provided through a political subdivision pursuant to §504.053(b)(2) of the Texas Labor Code, relating to directly contracting with health care providers or contracting through a health benefits pool? Yes No If yes, provide the name of the health care plan. 35. Check all body parts and diagnoses that apply: Spine and Torso Examples (not an exhaustive list) Cervical, Thoracic, Lumbar, Sacroiliac, Sacrum, Coccyx, Pelvis, Sternum and Manubrium, Rib Cage, Chest Wall, Abdominal Wall Shoulder including Glenohumeral and Acromioclavicular Joints, Clavicle, Sternoclavicular Joint, Scapula, Forearm, Arm, Elbow, Wrist, Hand, Finger Hip, Buttock, Thigh, Leg, Knee Foot, Heel, Toe Tooth, Jaw, Temporomandibular Joint (TMJ) Eye, Eyelid Internal Systems; Ear, Nose, and Throat; Head and Face; Skin; Mental and Behavioral Disorders; Tendon Lacerations; Dislocations N/A Spinal cord injuries, including spinal fractures with documented neurological deficit 3rd or 4th degree over 9% or greater of the body N/A Infection requiring hospitalization or prolonged intravenous antibiotics, including blood borne pathogens N/A N/A N/A Upper Extremities Lower Extremities (excluding feet) Feet Teeth and Jaw Eyes Other Body Areas or Systems Traumatic Brain Injury Spinal Cord Injuries Severe Burns (including chemical burns) Multiple Bone Fractures (excluding spinal fractures) Infectious Diseases (complicated) Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy) Chemical Exposure (excluding chemical exposure limited to skin exposure) Heart or Cardiovascular Condition For TDI-DWC Use Only Employee's Name: DWC Claim Number: DWC032 Rev. 01/13 Page 2 of 7 American LegalNet, Inc. www.FormsWorkFlow.com DWC032 VII. EXAMINATION / INJURY INFORMATION 36. Provide the specific reason(s) for the requested examination. The reason(s) must indicate how the examination will resolve a dispute or assist in the progression of the claim. 37. List all injuries determined to be compensable by TDI-DWC or accepted as compensable by the insurance carrier. (If using ICD codes, you must also provide descriptions.) 38. Has a previous designated doctor examination been performed for this claim? Yes No If No, skip boxes 39 - 41. 39. Regarding the most recent designated doctor examination, provide the following information: a. Name of the designated doctor b. Date of the examination (mm/dd/yyyy) 40. If approval of this request would result in the Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) scheduling an examination within 60 days of a previous designated doctor examination, provide good cause as to why it is necessary to schedule this examination within 60 days. 41. Explain any change of medical condition since the most recent designated doctor examination. For TDI-DWC Use Only Employee's Name: DWC Claim Number: DWC032 Rev. 01/13 American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 7 DWC032 VIII. PURPOSE FOR EXAMINATION 42. Requester: For items A through G below, check the box(es) next to the issue(s) you want the designated doctor to address and provide the requested information. Designated Doctor: Address only the issues that are checked. If Box A or B is checked, you must file the DWC Form-069. If Box E or F is checked, you must file the DWC Form-073. If Box C, D or G is checked, you must file the DWC Form-068. A. Maximum Medical Improvement (MMI) Statutory MMI Date (if any) (mm/dd/yyyy) Questions for the Designated Doctor to consider in the examination: Has MMI been reached; if so, on what date (may not be greater than the statutory MMI date shown above)? B. Impairment Rating (IR) MMI Date* (required only if Box A is not checked) (mm/dd/yyyy) *The MMI date that has been determined to be valid by a final decision of the TDI-DWC or court or by agreement of the parties. Question for the Designated Doctor to consider in the examination: As of the MMI date, what is the IR? C. Extent of Injury List all injuries (diagnoses/body parts/conditions) in question, claimed to be caused by, or naturally resulting from the accident or incident. Describe the accident or incident that caused the claimed injury. Question for the Designated Doctor to consider in the examination: Was the accident or incident giving rise to the compensable injury a
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