Texas > Workers Compensation > Other Business
Request For Copies Of Confidential Claimant Information DWC153 - Texas
| Request For Copies Of Confidential Claimant Information Form. This is a Texas form and can be used in Other Business Workers Compensation . |
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Send to: TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION 7551 Metro Center Drive, Suite 100, MS-92B Austin, TX 78744 REQUEST FOR COPIES OF CONFIDENTIAL CLAIMANT INFORMATION SUBMIT A SEPARATE DWC FORM-153 FOR EACH DWC OR IAB # Please carefully read the information on both sides of this form and the accompanying instructions. INCORRECTLY COMPLETED FORMS WILL BE RETURNED TO REQUESTOR WITHOUT ACTION. Use this form to request the confidential information listed below. This form must be signed by a party eligible to receive the information requested. The signature must be notarized. (Please type or print) I. CLAIM FILE IDENTIFICATION. Provide the following information to identify the requested claim file. CLAIM or IAB Number Employee's Name Last First MI Employee's Social Security Number Employee's Date of Injury -m m d d -y y --- II. REQUESTOR INFORMATION. Provide the following information pertaining to the requestor. Name Address City, State ZIP DWC/Representative Box No. (If Applicable): Prepaid Account No. (If Applicable): Telephone No. ( ) Authorized Legal Representative Statement on File III. INFORMATION REQUESTED. Please indicate the information and services requested. Copy Fees: $1.00/first page - $0.30/each additional page. Certification Fee: $1.00 CLAIM FILE INFORMATION - DWC REPROGRAPHICS DEPARTMENT - (512) 804-4990 Provides paper copies of claim information maintained by the Division in the original claim file and/or electronic data stored on DWC computer. Certified Uncertified Expedited Handling Request ($25.00 Additional Charge) Claim File (Complete) Specific document in file:____________________________ Other (Specify) ___________________________________ Dispute Resolution Contact Data (Electronic) A FEE STATEMENT WILL BE SENT TO REQUESTOR. COPIES WILL BE AVAILABLE UPON RECEIPT OF PAYMENT. MEDICAL RECORDS INFORMATION - DWC MEDICAL REVIEW DIVISION - (512) 804-4812 Provides paper copies of claim information maintained in specific DWC Medical records. Tracking No: Expedited Handling Request ($25.00 Additional Charge) Spinal Surgery File (Complete) Specific File Document Medical Dispute Resolution Contact Data (Electronic) A FEE STATEMENT WILL BE SENT TO REQUESTOR. COPIES WILL BE AVAILABLE UPON RECEIPT OF PAYMENT. Medical Dispute File (Complete) HEARINGS RECORD - DWC HEARINGS - (512) 804-4060 Provides information received at DWC hearings pertaining to disputes between the health care provider, the carrier, the employee, the employer and/or DWC. (Applies to claims with date of injury after January 1, 1991 only.) Certified Uncertified DWC Docket No: Expedited Handling Requested ($25.00 Additional Charge) Complete Hearings Record Specific document in record: (example: transcript, original petition, etc.) Video Tape (if available) $5.72 Audio Tape $3.60 each REQUESTOR WILL BE ADVISED OF CHARGES. COPIES WILL BE AVAILABLE UPON RECEIPT OF PAYMENT. DEPOSIT REQUIRED FOR TAPE TRANSCRIPTION: $350.00/hour (estimate). COMPLETE DWC FORM-153 (Rev. 10/05) Page 1 BOTH SIDES DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.USCourtForms.com IMPORTANT: BY EXECUTING THIS FORM, REQUESTOR REPRESENTS THAT HE OR SHE IS ENTITLED TO THE INFORMATION REQUESTED AND THAT HE OR SHE HAS FULL AUTHORITY TO ACT AS A REQUESTOR. REQUESTOR ALSO ACKNOWLEDGES HIS OR HER LIABILITY FOR PAYMENT OF ALL AMOUNTS OWED FOR SERVICES PROVIDED AS A RESULT OF THIS REQUEST. IV. REQUESTOR ELIGILBITY AND NOTARIZATION. (PLEASE CHECK ONE BOX ONLY) The Texas Workers' Compensation Act, Texas Labor Code, Title 5, Section 402.084, limits the release of confidential information in or derived from a claim file to the categories of persons listed below. Indicate the category of eligibility, which qualifies you to receive the information requested. Sign and complete the notarization prior to sending the request to DWC. Eligibility will be verified. The employee or the employee's legal beneficiary The employee's or the legal beneficiary's representative (attach letter of representation) The employer at the time of injury. Requestor must provide injured employee's period of employment: mo./yr The workers' compensation insurance carrier. Requestor must provide injured employee's date of injury or current claim: mo./dy./yr. The Texas Property and Casualty Insurance Guaranty Association, if that association has assumed the obligations of an impaired insurance company A third party litigant in a lawsuit, in which the cause of action arises from the incident that gave rise to the injury. (COPY OF PETITION AND ANSWER MUST BE ATTACHED). Requestor must provide injured employee's date of injury mo/yr to mo./yr. The Texas Certified Self-Insurer Guaranty Association Established under Subchapter G, Chapter 407, if that association has assumed the obligations of an impaired employer Health Care Provider who is a party to a Medical Dispute. (Section 413.031 of the Act.) I have read and understood this form and the accompanying instructions. I am entitled to receive the confidential employee information being requested as indicated above. I understand that it is a Class A misdemeanor to unlawfully receive, publish, disclose, or distribute confidential information in or derived from an employee's claim file. [Texas Labor Code, Sections 402.064; 402.081; 402.083 - .084; 402.086 and 402.091] Name of Requestor: (Please Print) Position/Title: Firm Name: (if applicable) Federal Tax I.D.#: Signature: Date State of County of * * * , who Before me on the above date personally appeared after first being sworn, said that the statements contained in this request are true. Signed Notary Public, State of My Commission Expires DWC FORM-153 (Rev. 10/05) Page 2 DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.USCourtForms.com DWC FORM - 153 REQUEST FOR COPIES OF CONFIDENTIAL CLAIMANT INFORMATION INSTRUCTIONS www.tdi.state.tx.us 1. DWC FORM-153 MUST BE COMPLETED IN ITS ENTIRETY. Please print or type. Send a separate DWC FORM-153 request form for each CLAIM number for which you are requesting copies of confidential employee information. A requestor MUST indicate in Section IV the legal basis on which he/she is eligible to receive requested confidential employee information. Only individuals in the categories listed are entitled to receive copies of confidential information. See Texas Workers' Compensation Act, Texas Labor Code, Section 402.084. A. B. An eligible insurance carrier must have handled a workers' compensation claim f
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