Texas > Workers Compensation > Medical
Designated Doctor Examination Data Report DWC-68 - Texas
| Designated Doctor Examination Data Report Form. This is a Texas form and can be used in Medical Workers Compensation . |
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DWC068 Texas Department of Insurance Division of Workers' Compensation 7551 Metro Center Drive, Suite 100 · MS 94 Austin, TX 78744-1645 (800) 252-7031 phone · (512) 490-1047 fax Complete if known: DWC Claim # Carrier Claim # Designated Doctor Examination Data Report Extent of Injury, Disability, or Other Similar Issues I. INJURED EMPLOYEE CLAIM INFORMATION 1. Employee Name (Last, First, Middle) 3. Insurance Carrier Name 2. Employee Social Security Number 4. Date of Injury (mm-dd-yyyy) II. EXAMINATION INFORMATION 5. Designated Doctor Name 6. Designated Doctor Mailing Address (Street or PO Box, City, State, Zip Code) 7. Designated Doctor License Number 9. Designated Doctor License Type 11. Examination Location (Street, City, State, Zip Code) 12. Date and Time of Appointment 13. Does the claim involve medical benefits provided through a Certified Health Care Network? Yes No 8. Designated Doctor License Jurisdiction 10. Designated Doctor Phone Number ( ) If yes, provide the name of the network. 14. 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. For TDI-DWC Use Only DWC068 Rev. 09/12 Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com DWC068 III. DIAGNOSIS CODES FOR COMPENSABLE DIAGNOSES/CONDITIONS 15. Refer to the DWC Form-032 you received for this examination and provide below all the diagnoses/conditions listed in Section VII, Box 37. For data purposes only, assign the most reasonable corresponding diagnosis code(s) for each compensable diagnosis/condition listed. You may assign up to four diagnosis codes for each compensable diagnosis/condition. Attach additional pages, if necessary. For Data Purposes Only Diagnosis Diagnosis Code 2 Code 3 Compensable Diagnosis/Condition 1) 2) 3) 4) 5) 6) 7) 8) IV. PURPOSE OF EXAMINATION Diagnosis Code 1 Diagnosis Code 4 16. Issues considered during Designated Doctor's examination. Check only the items that were included on the DWC Form-032 and provide the requested information. a) Extent of Injury Refer to the DWC Form-032 you received for this examination and provide below all the diagnoses/conditions listed in Section VIII, Box 42C. Did you determine that the accident or incident giving rise to the compensable injury was a substantial factor in bringing about the additional claimed diagnoses/conditions, and without it, the additional diagnoses/conditions would not have occurred? Provide your answer below by checking Yes or No for each additional claimed diagnosis/condition. For data purposes only, assign the most reasonable corresponding diagnosis code(s) for each additional claimed diagnosis/condition. You may assign up to four diagnosis codes for each additional claimed diagnosis/condition. Attach additional pages, if necessary. Additional Claimed Diagnosis or Condition 1) 2) 3) 4) 5) 6) 7) 8) For TDI-DWC Use Only Yes No Diagnosis Code 1 For Data Purposes Only Diagnosis Diagnosis Code 2 Code 3 Diagnosis Code 4 Employee's Name: DWC Claim Number: DWC068 Rev. 09/12 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com DWC068 b) Disability - Direct Result Did you determine that the employee's inability to obtain and retain employment at wages equivalent to the preinjury wage is a direct result of the compensable injury? Yes No Refer to the DWC Form-032 you received for this examination and provide the following information as shown in Section VIII, Box 42D: Provide the beginning and ending dates for the claimed periods of disability? If multiple periods, list all dates. From to (mm/dd/yyyy) c) Other Similar Issues Refer to the DWC Form-032 you received for the examination and describe the issue(s) listed in Section VIII, Box 42G, and provide your response to the issue(s). V. REFERRALS / ADDITIONAL TESTING 17. Provide the requested information regarding referrals and additional testing for this examination. Type of Testing Psychological Testing / Evaluation X-Ray (mm/dd/yyyy) FCE (Functional Capacity Evaluation); EMG (Electromyography); NCV (Nerve Conduction Velocity); MRI (Magnetic Resonance Imaging); CT-Scan (Computed Tomography Scan) VI. DESIGNATED DOCTOR'S SIGNATURE 18. Signature of Designated Doctor 19. Date of Signature (mm/dd/yyyy) For TDI-DWC Use Only Employee's Name: DWC Claim Number: DWC068 Rev. 09/12 Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Other FCE MRI Referral Health Care Provider Name CT-Scan Provider License Number Date of Service EMG / NCV DWC068 Frequently Asked Questions Designated Doctor Examination Data Report Extent of Injury, Disability, or Other Similar Issues (DWC Form-068) Under what circumstances is the DWC Form-068 filed? The DWC Form-068 must be filed when a designated doctor examination addresses issues of extent of injury, disability direct result, or other similar issues. Do not file this form if the designated doctor examination only addressed issues of maximum medical improvement, impairment rating, and/or return to work. Is a narrative report required when filing the DWC Form-068? Yes. You must attach the narrative report required by 28 Texas Administrative Code §127.220, Designated Doctor Narrative Reports. Where do I file the DWC Form-068? The DWC Form-068, along with the narrative report, must be submitted as follows: · · Send to the treating doctor, TDI-DWC, and the insurance carrier by facsimile or electronic transmission. Send to the injured employee and the injured employee's representative (if any) by facsimile or electronic transmission if you have this information. Otherwise, you must send the reports by other verifiable means. NOTE : Title 28 Texas Administrative Code §127.220(c) requires a designated doctor who performs an examination under §127.10(f) to file a Designated Doctor Examination Data Report in the form and manner required by TDI-DWC. The social security number may be used to identify the injured employee. 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). DWC068 Rev. 09/12 Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 1 2
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