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Request For Extension Of Maximum Medical Improvement For Spinal Surgery DWC-57 - Texas
| Request For Extension Of Maximum Medical Improvement For Spinal Surgery Form. This is a Texas form and can be used in Employee Workers Compensation . |
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DWC057 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) 804-4378 fax Complete if known: DWC Claim # Carrier Claim # Request for Extension of Maximum Medical Improvement Date for Spinal Surgery I. INJURED EMPLOYEE/EMPLOYEE REPRESENTATIVE INFORMATION 1. Injured Employee's Name (First, Middle, Last) 2. Injured Employee's SSN (last 4 digits) xxx-xx3. Injured Employee's Address (Street or PO Box, City, State, Zip Code) 4. Injured Employee's Phone Number ( ) 6. Representative's Name (if applicable) 5. Alternate Phone Number (if available) ( ) 7. Date of Injury (mm/dd/yyyy) 8. Representative's Address (Street or PO Box, City, State, Zip Code) II. EMPLOYER INFORMATION (at the time of the injury) 9. Employer's Name 10. Employer's Address (Street or PO Box, City, State, Zip Code) III. INSURANCE CARRIER/ADJUSTER INFORMATION 11. Insurance Carrier's Name 12. Adjuster's Name 14. Adjuster's E-mail (if known) 13. Adjuster's License Number (if known) 15. Adjuster's Phone Number 16. Adjuster's Fax Number ( ) ext. ( ) IV. SPINAL SURGERY INFORMATION 17. Treating Doctor's Name 19. Treating Doctor's Address (Street or PO Box, City, State, Zip Code) 20. Surgeon's Name 22. Surgeon's Address (Street or PO Box, City, State, Zip Code) 23. Date spinal surgery was approved (mm/dd/yyyy) 18. Treating Doctor's Phone Number ( ) 21. Surgeon's Phone Number ( ) For TDI-DWC Use Only 24. Date spinal surgery is scheduled or was performed (mm/dd/yyyy) DWC057 Rev. 02/13 Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com DWC057 V. REQUEST FOR MMI EXTENSION / REQUESTER CERTIFICATION 25. Check the appropriate box to identify the party requesting the extension: Injured Employee Injured Employee Representative Insurance Carrier Pursuant to Texas Labor Code §408.104 and 28 Texas Administrative Code §126.11, I hereby apply to extend the statutory maximum medical improvement date for spinal surgery and I certify that prior to submitting this form to the TDI-DWC: a. I requested information as specified on page 3 of this form from the treating doctor or surgeon. b. On the same day I sent the request to the treating doctor or surgeon, I sent a copy of the request to the other party, i.e. insurance carrier or injured employee/injured employee's representative. c. Check the appropriate box and provide applicable dates regarding the treating doctor or surgeon's response. The response from the treating doctor or surgeon is attached. Request sent to treating doctor/surgeon on (mm/dd/yyyy) and no reply received as of (mm/dd/yyyy) . d. On the same day I sent this form (DWC Form-057) to the TDI-DWC, I sent a copy of the form to the other party, i.e. insurance carrier or injured employee/injured employee's representative. Printed Name of Requester ______________________________________________________ __________ Signature of Requester ___________________________________________ Date Frequently Asked Questions Request for Extension of Maximum Medical Improvement Date for Spinal Surgery (DWC Form-057) Who can file the DWC Form-057? An injured employee, injured employee's representative or insurance carrier may file the DWC Form-057 to request an extension of the statutory maximum medical improvement (MMI) date for spinal surgery. In the answers to the following questions, the person requesting the extension is referred to as "the requester" or "you". Under what circumstances is it appropriate to file the DWC Form-057? It is appropriate to file the DWC Form-057 only if all of the following conditions have been met: · · · · The injured employee had spinal surgery or spinal surgery has been approved. MMI has not been reached prior to the request. "Reached" means certified and a) not disputed, or b) if disputed, dispute has been resolved. The date of injury was after January 1, 1998. The requester complied with the following requirements of 28 Texas Administrative Code §126.11(c) and (f). For TDI-DWC Use Only Employee's Name: DWC Claim Number: DWC057 Rev. 02/13 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com DWC057 Prior to submitting the request for an extension of the statutory MMI date to the TDI-DWC, you must request from the treating doctor or surgeon the following information: · · · · · · typical recovery times for the specific spinal surgery procedure; the projected date and information regarding when the condition will be medically stable; case specific information regarding any extenuating circumstances that may have resulted in variances from conservative treatment protocols and time frames or that may impact recovery times; information from any source regarding intentional or non-intentional delays in securing the surgery or medical treatment; any pending or unresolved disputes regarding the date of maximum medical improvement; and information provided by the insurance carrier, injured employee or injured employee's representative, if any, regarding the extension being requested. On the same day you send the request to the treating doctor or surgeon, you must also send a copy of the request by first class mail to the other party, i.e. insurance carrier or injured employee/injured employee's representative. TDI-DWC rules require the treating doctor or surgeon to provide the information to you within ten days of receiving the request. However, if you do not receive a response within 15 days, you may submit the DWC Form-057 without attaching the information. When can I file the DWC Form-057? The form requesting an extension of the statutory MMI date for spinal surgery must be received by the TDI-DWC: · · no earlier than 92 weeks, and no later than 110 weeks after income benefits began to accrue. How do I file the DWC Form-057? Submit the DWC Form-057 to the TDI-DWC by: · · · faxing the form to (512) 804-4378; mailing the form to the address at the top of the form; or personally delivering or mailing the form by first class mail to the local TDI-DWC field office. Field office addresses can be found on the agency website at http://www.tdi.texas.gov/wc/dwccontacts.html#offices. What will TDI-DWC do? After reviewing the documentation, the TDI-DWC will approve or deny the request. If approved, the TDI-DWC will issue an order stating the number of weeks that the MMI date has been extended and the end date of the extension. If denied, the order will state the reason(s). A copy of the order will be sent to the insuran
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