Blank Texas Dwc022 PDF Form Get Texas Dwc022 Here

Blank Texas Dwc022 PDF Form

The Texas DWC022 form is a critical document used in the workers' compensation process, specifically for requesting a Required Medical Examination (RME). This form facilitates communication between the injured employee, their employer, and the insurance carrier regarding the need for medical evaluations related to work-related injuries. Understanding the details and requirements of the DWC022 form is essential for ensuring compliance and protecting the rights of all parties involved.

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The Texas DWC022 form plays a crucial role in the workers' compensation process, particularly when it comes to ensuring that injured employees receive appropriate medical evaluations. This form is primarily utilized by insurance carriers to request a Required Medical Examination (RME) for various reasons, including assessing the appropriateness of health care received or evaluating determinations made by designated doctors. It gathers essential information about the injured employee, their employer, and the insurance carrier, ensuring that all parties are informed and involved in the process. Sections of the form require details such as the employee’s name, contact information, and specifics about the injury, along with the insurance adjuster's information. Additionally, the form includes sections dedicated to the examination details, including the examining doctor's information and the purpose of the examination. Notably, it also outlines the responsibilities of the insurance carrier, emphasizing the importance of accuracy and compliance with Texas labor laws. Understanding the nuances of the DWC022 form is vital for both employees and employers, as it helps facilitate timely medical evaluations and ensures that all procedural requirements are met.

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DWC022
DWC022 Rev. 06/23 Page 1 of 3
Request for a required medical examination (RME)
Este formulario
está disponible en español en el sitio web de la División en www.tdi.texas.gov/forms/form20numeric.html
Para obtener asistencia en español, llame a la División al 800-252-7031.
Section 1: Claim information
Part 1: Employee information
1. Name (first, middle, last)
2. Social Security number (last four digits)
XXX-XX-
3. Phone number
4. Address (street or PO box, city, state, ZIP code)
5. Date of injury (mm/dd/yyyy)
6. Representative’s name (if any)
7. Representative’s phone number
8. Representative’s address (street or PO box, city, state, ZIP code)
Part 2: Insurance carrier information
9. Name
10. Address (street or PO box, city, state, ZIP code)
11. Adjuster’s name (first, last)
12. Adjuster’s email
13. Adjuster’s phone number
14. Authorized agent’s company name
15. Adjuster’s fax number
16. Authorized agent’s phone number
17. Are the medical benefits for this claim from a certified health care network?
☐ Yes ☐ No If yes, provide the name of the network.
18. Are the medical benefits for this claim from a political subdivision under Labor Code Section
504.053? ☐ Yes
☐
No If yes, provide the name of the health care plan.
Section 2: Examination information
19. Doctor’s name
20. Doctor’s license number
21. Doctor’s phone number
22. Date and time of appointment (mm/dd/yyyy)
Employee’s name:
DWC claim number:
Complete if known:
DWC claim #
Insurance carrier claim #
DWC022
DWC022 Rev. 06/23 Page 2 of 3
23. Examination location (street, city, state, ZIP code)
24. Is the examination location more than 75 miles from the employee’s address?
☐ Yes ☐ No If yes, explain why the employee is required to travel.
Section 3: Purpose of examination (Complete only Part 1 or Part 2)
Part 1: Issues previously addressed by a designated doctor (Check all that apply)
☐
Maximum medical improvement
☐ Impairment rating
☐ Extent of injury
☐
Disability – direct result
☐
Return to work
☐ Return to work (supplemental income benefits)
☐ Other similar issues
Part 2: Appropriateness of health care
25. Date of previous examination (if any) (mm/dd/yyyy)
26. Are you requesting that the employee see a different doctor than the one who performed the
previous examination? ☐ Yes ☐ No If yes, provide the doctor’s name and reason for using a different
doctor.
27. Receipt of employee’s agreement for an examination under 28 Texas Administrative Code
Section 126.5(e). (Check only one box and provide dates.)
☐ Employee or representative notified the insurance carrier and agreed to attend the examination on
(mm/dd/yyyy) .
☐ Employee or representative notified the insurance carrier and did not agree to attend the examination
on (mm/dd/yyyy) .
☐ Insurance carrier sent this form to employee or representative on (mm/dd/yyyy) and no reply
was received as of (mm/dd/yyyy) .
28. Employee's agreement to attend the requested examination
☐
I agree ☐ I do not agree
Note: If the employee agrees, they must attend the examination at the scheduled time and location. If the
employee does not agree, the insurance carrier will submit the request for an RME to DWC for review. If
DWC approves the request, DWC will issue an order for the employee to attend the examination under
Texas Labor Code Section 408.004.
Signature
Date
Section 4: Certify with your signature
29. I certify that this request is complete and accurate. The doctor listed does not have a disqualifying
association, and I am authorized to act on behalf of the insurance carrier.
Signature
Date
30. Printed name
31. Job title
Employee’s name:
DWC claim number:
For DWC use only
DWC022
DWC022 Rev. 06/23 Page 3 of 3
FAQ
Request for a required medical examination (RME)
Why would an insurance carrier request an RME?
The insurance carrier may request this examination for:
• Issues ordered to be addressed in a designated doctor report: To have a doctor of their choice check the
same issues as the designated doctor and provide their opinion for each examination.
• Appropriateness of health care: To have a doctor of their choice examine whether the health care the injured
employee received is appropriate and provide an opinion. The carrier can’t request an exam for
appropriateness of health care if the claim is in a health care network or political subdivision.
Where should the insurance carrier send this form?
• Fax: 512-804-4378
• Mail: Texas Department of Insurance, Division of Workers' Compensation
Claims and Customer Services, Mail Code CCS
PO Box 12050
Austin, TX 78711-2050
Does the employee need to sign the form?
The employee only needs to sign the form when the purpose of the RME is for appropriateness of health care.
What does DWC do?
DWC will approve or deny the request and send the order to all parties.
Can the RME be rescheduled?
Yes, the employee and RME doctor must contact each other 24 hours or earlier before the examination date to
reschedule. If the employee fails to attend the examination, DWC may submit an administrative violation.
What if the employee must t
ravel to the RME?
If the examination is 30 miles or more from where the employee lives, the employee may request reimbursement for
travel expenses from the insurance carrier using DWC Form-048, Request for Travel Reimbursement at
www.tdi.texas.gov/forms/formlisting.html
.
Questions?
Call 1-800-252-7031, Monday to Friday, 8 a.m. to 5 p.m., Central time.
Go to www.tdi.texas.gov/wc
to learn more about workers’ compensation.
Note: With few exceptions, on your request, you are entitled to:
• be informed about the information DWC collects about you;
• receive and review the information (Government Code Sections 552.021 and 552.023); and
• have DWC correct information that is incorrect (Government Code Section 559.004).
For more information, contact DWCLegalServices@tdi.texas.gov or go to the Corrections Procedure section at
www.tdi.texas.gov.
⇓ Texas Dwc022 PDF

Document Specs

Fact Name Details
Purpose of the Form The DWC022 form is used to request a Required Medical Examination (RME) by the insurance carrier. It serves two primary purposes: evaluating a Designated Doctor's determination or assessing the appropriateness of health care received.
Governing Laws This form is governed by the Texas Labor Code, specifically sections §408.004 and §504.053, which outline the procedures for medical examinations and the handling of workers' compensation claims.
Submission Timeline After the insurance carrier sends the request, the injured employee has 15 days to respond by completing the agreement/non-agreement section of the form. Failure to respond may lead to further actions by the insurance carrier.
Frequency of Examinations An RME to determine the appropriateness of health care cannot occur more than once every 180 days. However, evaluations related to a Designated Doctor's determination can happen more frequently.
Travel Reimbursement If travel is required for the examination, the injured employee can request reimbursement for travel expenses. This request must be submitted using the DWC-Form 048.
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