Texas > Workers Compensation > Employee
Request To Schedule, Reschedule, Or Cancel A Benefit Review Conference (BRC) DWC-45 - Texas
| Request To Schedule, Reschedule, Or Cancel A Benefit Review Conference (BRC) Form. This is a Texas form and can be used in Employee Workers Compensation . |
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DWC045 Texas Department of Insurance Division of Workers' Compensation 7551 Metro Center Drive, Suite100 · MS-94 Austin, TX 78744-1645 (800) 252-7031 phone · (512) 804-4378 fax Complete if known: DWC Claim # Carrier Claim # Send completed form to TDI-DWC field office handling the claim Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC) Type (or print in black ink) each item on this form I. REQUEST SPECIFICATIONS 1. Check ONLY one box to indicate the purpose of your request: 2. Check applicable box(es) for services you are requesting: Special Accommodations (Please specify) ____________________________________________ Schedule a BRC Reschedule a BRC Cancel a BRC Expedited BRC (Provide reason) ____________________________________________ II. INJURED EMPLOYEE CLAIM INFORMATION 3. Employee's Name (Last, First, Middle) 5. Insurance Carrier's Name 8. Employer's Business Name (at the time of the injury) 4. Employee's Physical Address 6. Date of Injury (mm-dd-yyyy) 7. Employee's SSN 9. Employer's Business Address III. PARTY REQUESTING TO SCHEDULE, RESCHEDULE OR CANCEL A BENEFIT REVIEW CONFERENCE 10. Check the appropriate box: Injured Employee Insurance Carrier Employer Sub-claimant Beneficiary Attorney for Yes No 11. Is the injured employee assisted by the Office of the Injured Employee Counsel (OIEC)? 12. Requester's Typed or Printed Name 14. Business/Firm Name (if applicable) 13. Requester's Mailing Address (Street or PO Box, City State Zip) 15. Phone Number 16. Alternate Phone Number Request to SCHEDULE a Benefit Review Conference (Complete Sections IV and V) IV. ISSUE(S) TO BE MEDIATED AT THE BENEFIT REVIEW CONFERENCE 17. Check applicable box(es) to identify the disputed issue(s): Compensability of the claim* Extent of the compensable injury Entitlement to temporary income benefits Entitlement to supplemental income benefits Average weekly wage determination Designated doctor's certification of maximum medical improvement Designated doctor's assessment of whole body impairment rating Entitlement to death benefits and/or burial benefits Failure of carrier or employer to provide employee required network information Other *An employer may check this box only if the insurance carrier has accepted liability. 18. Briefly describe each disputed issue (additional pages may be attached, if necessary). For TDI-DWC Use Only DWC045 Rev. 11/11 American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 3 DWC045 V. DOCUMENTATION OF YOUR EFFORTS TO RESOLVE THE ISSUE(S) 19. Provide the date the opposing party was notified of the disputed issues (mm-dd-yyyy): 20. Attach the following to this form: · a description of all efforts you have made to resolve the disputed issue(s) · supporting documentation NOTE: If this information is not provided, a BRC may not be scheduled. 21. I certify that prior to this request I have made reasonable efforts to resolve the disputed issue(s) identified in Section IV above and that any pertinent information in my possession has been provided to the opposing party or parties. I certify that all the information provided on this form is true and correct. I certify that I will provide a copy of this request to the opposing party or parties. Signature of Requester_______________________________________________________Date______________________ Request to RESCHEDULE or CANCEL a Benefit Review Conference (Complete Section VI) VI. DOCUMENTATION OF GOOD CAUSE FOR RESCHEDULING OR CANCELING A BENEFIT REVIEW CONFERENCE 22. Check ONE box below to indicate the description applicable to your request: Cancel PRIOR to BRC (Complete 23 and 26) Reschedule PRIOR to BRC (Complete 23, 25, and 26) Reschedule AFTER failing to attend BRC (Complete 24, 25, and 26) 23. If you are requesting to reschedule or cancel a BRC and the date you are submitting this form is more than 10 days after the date* you received the notice of setting but before the BRC is scheduled to be held, attach the indicated information and any supporting documentation to this form: a) a description of objective facts beyond your control, which reasonably: prevent you from attending the BRC; or prevent the BRC from accomplishing its purpose (This may include a description of your need for a reasonable amount of additional time to secure necessary evidence for the dispute); OR th b) a description of objective facts which make the BRC unnecessary. * The date the notice of setting is received is deemed to be the 5 day after the date of the notice. NOTE: If this information is not provided, the BRC may not be rescheduled or canceled. Canceling a BRC without simultaneously rescheduling is considered a withdrawal of the dispute on the issue and must comply with TDI-DWC rule 130.12, if applicable. If you did not submit the initial request for the BRC that you are requesting to reschedule or cancel, have you obtained the agreement of Yes No the opposing party to the rescheduling or cancelation of the BRC? 24. If you are requesting to reschedule after failing to attend a BRC, you must attach a description of objective facts beyond your control, which reasonably prevented you from attending the BRC and from notifying TDI-DWC to cancel or reschedule in advance of the BRC; If you do not submit the request by close of business on the third business day after the BRC was held, you must also attach a description of objective facts beyond your control, which reasonably prevented you from doing so and which justify the subsequent delay in filing the request. Attach any supporting documentation. NOTE: If this information is not provided, the BRC may not be rescheduled. 25. Check the appropriate box below: The information provided in the initial request for this BRC has not changed. Information provided in the initial request for this BRC has changed. (If this box is checked, you must complete Sections IV and V of this form.) 26. I certify that I will provide a copy of this request to the opposing party or parties. Signature of Requester__________________________________________________Date______________ For TDI-DWC Use Only NOTE: With few exceptions, upon your request, you are entitled to be informed about the information TDI-DWC collects about you; receive and review the information (Government Code, §§552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government Code, §559.004). DWC045 Rev. 11/11 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 DWC045 Frequently Asked Questions R
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