Texas > Workers Compensation > Medical
Designated Doctor Certification Application DWC-67 - Texas
| Designated Doctor Certification Application Form. This is a Texas form and can be used in Medical Workers Compensation . |
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DWC067 Texas Department of Insurance Division of Workers' Compensation 7551 Metro Center Drive, Suite 100 · MS-603 Austin, TX 78744-1645 (512) 804-4766 phone · (512) 804-4207 fax Designated Doctor Certification Application Initial Certification Recertification Date current certification expires, if applicable (mm/yyyy) I. APPLICANT / INDIVIDUAL INFORMATION (not administrative services company / agent information) 1. Name (Last, First, Middle, Suffix) 2. Social Security Number 3. Date of Birth (mm/dd/yyyy) 4. Home Mailing Address (Street or PO Box, City, State, Zip Code) 5. Business Mailing Address (Street or PO Box, City, State, Zip Code) 6. Home Phone Number 7. Alternate Phone Number ( ) ( ) 8. Fax Number 9. E-mail Address ( ) 10. Non-English Language Spoken by Applicant Yes No If yes, specify 11. Non-English Language Spoken by Office Personnel Yes No If yes, specify II. LICENSE INFORMATION (attach additional pages, if necessary) Texas License 12. License Type 13. License Number Other License (if applicable) 17. License Type 18. License Number Other License (if applicable) 22. License Type 23. License Number 14. State of Registration 19. State of Registration 24. State of Registration Texas 15. Original Date of Issue (mm/yyyy) 20. Original Date of Issue (mm/yyyy) 25. Original Date of Issue (mm/yyyy) 16. Expiration Date (mm/yyyy) 21. Expiration Date (mm/yyyy) 26. Expiration Date (mm/yyyy) For TDI-DWC Use Only DWC067 Rev. 09/12 Page 1 of 7 American LegalNet, Inc. www.FormsWorkFlow.com DWC067 III. PROFESSIONAL SPECIALTY INFORMATION (attach additional pages, if necessary) Initial certification date (mm/yyyy) 27. Primary Specialty Are you board certified in this specialty? Yes No If yes, provide the name of certifying board 28. Secondary Specialty Are you board certified in this specialty? Yes No If yes, provide the name of certifying board 29. Additional Specialty Are you board certified in this specialty? Yes No If yes, provide the name of certifying board Recertification dates, if applicable (mm/yyyy) Expiration date, if applicable (mm/yyyy) Initial certification date (mm/yyyy) Recertification dates, if applicable (mm/yyyy) Expiration date, if applicable (mm/yyyy) Initial certification date (mm/yyyy) Recertification dates, if applicable (mm/yyyy) Expiration date, if applicable (mm/yyyy) IV. EDUCATION (attach additional pages, if necessary) 30. Professional Degree Medical/Osteopathic Chiropractic Optometry 31. Institution 32. Degree 34. Address (Street or PO Box, City, State, Zip Code) 35. Post-Graduate Education Internship Residency Teaching Appointment 38. Institution Podiatry Dentistry 33. Attendance Dates (mm/yyyy) From to 36. Program Director Fellowship 37. Current Program Director (if known) 39. Program Specialty 40. Attendance Dates (mm/yyyy) From to 41. Address (Street or PO Box, City, State, Zip Code) 42. Program Completed Successfully Yes No 43. Post-Graduate Education 44. Program Director 45. Current Program Director (if known) Internship Residency Fellowship Teaching Appointment 46. Institution 47. Program Specialty 48. Attendance Dates (mm/yyyy) From to 49. Address (Street or PO Box, City, State, Zip Code) 50. Program Completed Successfully Yes No 51. Other Graduate-Level Education Field of study 52. Institution 53. Degree 54. Attendance Dates (mm/yyyy) From to 55. Address (Street or PO Box, City, State, Zip Code) For TDI-DWC Use Only Applicant's Name: Applicant's SSN: DWC067 Rev. 09/12 Page 2 of 7 American LegalNet, Inc. www.FormsWorkFlow.com DWC067 V. ACTIVE PRACTICE / WORK HISTORY INFORMATION Active Practice 56. Have you maintained an active practice* for at least 3 years? Yes No *Active practice is defined as maintaining routine office hours of at least 20 hours per week for 40 weeks per year for the treatment of patients. Work History (attach additional pages, if necessary) 57. Current Practice / Employer Name (if any) 58. Start Date / End Date (mm/yyyy) From to 59. Address (Street or PO Box, City, State, Zip Code) 60. Previous Practice / Employer Name 62. Address (Street or PO Box, City, State, Zip Code) 63. Previous Practice / Employer Name 65. Address (Street or PO Box, City, State, Zip Code) 66. Previous Practice / Employer Name 68. Address (Street or PO Box, City, State, Zip Code) VI. WORKERS' COMPENSATION HEALTH CARE NETWORK AFFILIATIONS List all current workers' compensation health care network (network) affiliation(s) pursuant to Insurance Code §1305 and affiliation(s) with political subdivision health care plan(s) pursuant to Texas Labor Code §504.053(b)(2). Enter the contract start date for each network and each health care plan. (attach additional pages, if necessary) 61. Start Date / End Date (mm/yyyy) From to 64. Start Date / End Date (mm/yyyy) From to 67. Start Date / End Date (mm/yyyy) From to 69. Network / Health Care Plan Name 71. Network / Health Care Plan Name 73. Network / Health Care Plan Name 70. Start Date (mm/dd/yyyy) 72. Start Date (mm/dd/yyyy) 74. Start Date (mm/dd/yyyy) VII. ADMINISTRATIVE SERVICES COMPANY / BILLING AGENT / OTHER AGENT AFFILIATIONS List all current administrative services company, billing agent, and other agent affiliation(s) (attach additional pages, if necessary) 75. Administrative Services Company / Agent Name 76. Contract Start Date (mm/dd/yyyy) 77. Administrative Services Company / Agent Address (Street or PO Box, City, State, Zip Code) 78. Name of Point of Contact 80. Email Address of Point of Contact 82. Billing Agent Name 79. Phone Number of Point of Contact ( ) 81. Fax Number of Point of Contact ( ) 83. Billing Agent Phone Number ( ) For TDI-DWC Use Only Applicant's Name: Applicant's SSN: DWC067 Rev. 09/12 Page 3 of 7 American LegalNet, Inc. www.FormsWorkFlow.com DWC067 VIII. DISCLOSURE QUESTIONS (check YES or NO for each question) 84. Licensure Has your license to practice, in your profession, ever been denied, suspended, revoked, restricted, voluntarily surrendered while under investigation, or have you ever been subject to a consent order, probation or any conditions or limitations by any state licensing board? Have you ever received a reprimand or been fined by any state licensing board? 85. Hospital Privileges and Other Affiliations Have your clinical privileges or Medical Staff membership at any hospital or health care institution ever been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions (for reasons other than non-completion of med
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