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Request To Schedule, Reschedule, Or Cancel A Benefit Review Conference To Appeal A Medical Fee Dispute Decision DWC-45M - Texas
| Request To Schedule, Reschedule, Or Cancel A Benefit Review Conference To Appeal A Medical Fee Dispute Decision Form. This is a Texas form and can be used in Employee Workers Compensation . |
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DWC045M 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 # Request to Schedule, Reschedule, or Cancel a Benefit Review Conference to Appeal a Medical Fee Dispute Decision (BRC-MFD) 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: Schedule a BRC-MFD Reschedule a BRC-MFD Cancel a BRC-MFD 2. Check the appropriate box(es) for services you are requesting, if any: Special Accommodations (specify) Expedited BRC-MFD (specify reason*) _____________________________ ____________________________________________ *Does not include claim involving a first responder. See Section III, Box 11 regarding expedited first responder claims. Telephonic BRC-MFD II. INJURED EMPLOYEE CLAIM INFORMATION 3. Employee's Name (Last, First, Middle) 5. Employee's Physical Address (Street, City, State, Zip Code) 6. Insurance Carrier's Name 8. Employer's Business Name (at the time of the injury) 9. Employer's Business Address (Street or PO Box, City, State, Zip Code) 4. Employee's SSN* 7. Date of Injury (mm/dd/yyyy) *Title 28 Texas Administrative Code §141.1(d) requires that in order to schedule a benefit review conference, a request must be submitted in the form and manner required by TDI-DWC. Provision of the social security number is not mandatory, but failure to provide that number may result in delay of the request. The social security number may be used to identify the injured employee. III. PARTY REQUESTING TO SCHEDULE, RESCHEDULE, OR CANCEL A BRC-MFD 10. Check the appropriate box: Sub-claimant Injured Employee Insurance Carrier Health Care Provider Pharmacy Processing Agent 11. If Injured Employee is checked in Box 10, provide the following information: Is the injured employee a first responder, as defined in Texas Labor Code §504.055, who sustained a serious bodily injury*? Yes No If Yes, the BRC-MFD will be expedited. *bodily injury that creates a substantial risk of death or that causes death, serious permanent disfigurement, or protracted loss or impairment of the function of any bodily member or organ 12. Is the injured employee assisted by the Office of Injured Employee Counsel (OIEC)? 13. Requester's Printed Name 14. Requester's Mailing Address (Street or PO Box, City, State, Zip Code) 15. Business/Firm Name (if applicable) 16. Phone Number DWC045M Rev. 06/12 Yes No For TDI-DWC Use Only 17. Alternate Phone Number Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com DWC045M Request to SCHEDULE a BRC-MFD (Complete Section IV) IV. DOCUMENTATION OF YOUR EFFORTS TO RESOLVE THE MEDICAL FEE DISPUTE 18. To document your efforts to resolve the medical fee dispute, you must attach a copy of the TDI-DWC Medical Fee Dispute Resolution decision to this request. I certify I will provide a copy of this request to the opposing party or parties. I further certify that any pertinent information in my possession that was not previously exchanged during the Medical Fee Dispute Resolution process has been provided to the opposing party or parties. Signature of Requester_________________________________________ Date_ __________ Request to RESCHEDULE or CANCEL a BRC-MFD (Complete Section V) V. DOCUMENTATION OF GOOD CAUSE FOR RESCHEDULING OR CANCELING A BRC-MFD 19. Check ONE box below to indicate the description applicable to your request: Reschedule or cancel PRIOR to BRC-MFD (Complete 20 and 22) Reschedule AFTER failing to attend BRC-MFD (Complete 21 and 22) 20. If you are requesting to reschedule or cancel a BRC-MFD 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-MFD 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-MFD; or prevent the BRC-MFD from accomplishing its purpose (may include a description of your need for a reasonable amount of additional time to secure necessary evidence for the dispute); OR b) a description of objective facts which make the BRC-MFD unnecessary. *The date the notice of setting is received is deemed to be the 5th day after the date of the notice. NOTE: If this information is not provided, the BRC-MFD may not be rescheduled or canceled. Canceling a BRC-MFD without simultaneously rescheduling is considered a withdrawal of the dispute on the issue and must comply with TDI-DWC rules, 28 Texas Administrative Code §130.12, if applicable. If you did not submit the initial request for the BRC-MFD that you are requesting to reschedule or cancel, have you obtained the agreement of the opposing party to the rescheduling or cancelation of the BRC-MFD? Yes No For TDI-DWC Use Only Employee's Name: DWC Claim Number: DWC045M Rev. 06/12 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com DWC045M 21. If you are requesting to reschedule after failing to attend a BRC-MFD, you must attach a description of objective facts beyond your control, which reasonably prevented you from attending the BRC-MFD and from notifying the TDI-DWC to cancel or reschedule in advance of the BRC-MFD. If you do not submit the request by close of business on the third business day after the BRC-MFD 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-MFD may not be rescheduled. 22. I certify that I will provide a copy of this request to the opposing party or parties. Signature of Requester_________________________________________ Date_ ___________ NOTE: With few exceptions, upon your request, you are entitled to be informed about 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). Frequently Asked Questions Request to Schedule, Reschedule, or Cancel a Benefit Review Conference to Appeal a Medical Fee Dispute Decision (BRC-MFD) NOTE: This form may only be used to request the scheduling, rescheduling, or cancelation of a Benefit Review Conference for the ap
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