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Blank Texas Dwc022 PDF Form

The Texas DWC022 form is a crucial document used in the workers' compensation process, specifically for requesting a Required Medical Examination (RME). This form is essential for both employees and insurance carriers, as it facilitates the evaluation of medical care related to work injuries. Understanding how to properly fill out and submit this form can significantly impact the outcome of a claim.

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Content Overview

The Texas DWC022 form plays a crucial role in the workers' compensation process, specifically concerning Required Medical Examinations (RMEs). This form is primarily utilized by insurance carriers to request an examination of an injured employee by a doctor of their choice. It serves two main purposes: to evaluate the determination made by a designated doctor and to assess the appropriateness of health care that the employee has received. The form collects essential information about the employee, employer, and insurance carrier, ensuring that all parties are accurately represented. Sections of the form require details such as the employee's name, date of injury, and the specifics of the examination, including the doctor’s information and appointment details. Additionally, the form includes sections for the insurance carrier to certify the accuracy of the request and for the injured employee to indicate their agreement or disagreement with attending the examination. Understanding the DWC022 form is vital for both employees and insurance representatives, as it outlines the necessary steps and obligations involved in the RME process.

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DWC022

DWC022 Rev. 07/11 Page 1 of 3

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

Si desea hablar con alguien sobre este

formulario o acerca de su reclamación,

llame al ajustador de su aseguradora al

número de teléfono que aparece en la

Casilla 15 de la Sección III.

Complete if known:

DWC Claim #

Carrier Claim #

Required Medical Examination (RME) - Request for Agreement / Request for Order

I. EMPLOYEE/EMPLOYEE’S ATTORNEY INFORMATION

1. Employee's Name (First, Middle, Last)

2. Employee’s Social Security Number

3. Employee’s Address (Street or PO Box, City State Zip)

4. Employee’s Telephone Number

( )

5. Alternate Telephone Number (if available)

( )

6. Date of Injury (mm/dd/yyyy)

7. Attorney/Representative’s Name (if applicable)

8. Attorney/Representative’s Address (Street or PO Box, City State Zip)

II. EMPLOYER INFORMATION (at the time of the injury)

9. Employer’s Name

10. Employer’s Address (Street or PO Box, City State Zip)

III. INSURANCE CARRIER INFORMATION

11. Insurance Carrier's Name

12. Insurance Carrier's Address (Street or PO Box, City State Zip) 13. Adjuster’s Name

14. Adjuster’s E-mail

15. Adjuster’s Telephone Number

( ) ext.

16. Adjuster’s Fax Number

( )

17. Adjuster’s License Number

REQUEST FOR RME: EVALUATION OF DESIGNATED DOCTOR DETERMINATION (Complete Sections IV, V and VI)

IV. EXAMINATION INFORMATION

18. Examining RME Doctor's Name

19. RME Doctor’s Mailing Address (Street or PO Box, City State Zip)

20. RME Doctor’s License Number

21. RME Doctor's Telephone Number

( )

22. Examination Location (Street, City State Zip)

23. Date and Time of Appointment

24. Does the claim involve medical benefits provided through a Certified Health Care Network? Yes No If yes, provide the name of the network.

25. 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.

26. Are the employee’s address (Box 3) and the examination location (Box 22) more than 75 miles apart? Yes No

If yes, explain why the employee is being required to travel more than 75 miles for the examination.

V. PURPOSE OF EXAMINATION

27. Designated Doctor’s Name 28. Date of Designated Doctor examination

29. Issues in the Designated Doctor’s report to be addressed in requested RME. Check all that apply:

Maximum Medical Improvement Ability to return to work (DWC Form-073)

Impairment Rating Ability to return to work after the second anniversary of entitlement to

Extent of compensable injury supplemental income benefits (Texas Labor Code §408.151)

Whether disability is a direct result of work-related injury Other (explain)

VI. INSURANCE CARRIER CERTIFICATION

30. I hereby certify the following:

• This request is complete and accurate.

• The insurance carrier will pay reasonable expenses incident to the examination of the injured employee.

• The selected doctor does not have a disqualifying association.

• If the claim involves medical benefits provided through a political subdivision pursuant to §504.053(b) of the Texas Labor Code, this RME is

necessary to resolve an issue relating to the entitlement to or amount of income benefits as required by §504.053(c)(1) of the Texas Labor Code.

• I am authorized to act on behalf of the insurance carrier.

I understand that misrepresenting a workers’ compensation claim may result in enforcement action including administrative penalties and fines.

31. Signature of Adjuster or Authorized Insurance Carrier Representative For TDI-DWC Use Only

32. Printed Name of Adjuster or Authorized Insurance Carrier Representative

33. Title of Adjuster or Authorized Insurance Carrier Representative

34. Date of Signature

DWC022

DWC022 Rev. 07/11 Page 2 of 3

REQUEST FOR RME: APPROPRIATENESS OF HEALTH CARE RECEIVED (Complete Sections VII and VIII)

VII. EXAMINATION INFORMATION

35. Examining RME Doctor's Name

36. RME Doctor’s Mailing Address (Street or PO Box, City State Zip) 37. RME Doctor’s License Number

38. RME Doctor's Telephone Number

( )

39. Examination Location (Street, City State Zip) 40. Date and Time of Appointment

41. Date of Prior Examination

42. Prior Examining Doctor's Name

43. If different doctors are named in Boxes 35 and 42, explain the reason for requesting a different doctor.

44. Does the claim involve medical benefits provided through a Certified Health Care Network? Yes No If yes, provide the name of the network.

45. 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.

46. Are the employee’s address (Box 3) and the examination location (Box 39) more than 75 miles apart? Yes No

If yes, explain why the employee is being required to travel more than 75 miles for the examination.

VIII. INSURANCE CARRIER CERTIFICATION

47. I hereby certify the following:

• This request is complete and accurate.

• I have obtained the injured employee’s agreement or attempted to obtain the injured employee’s agreement for an examination under Texas Labor

Code §408.004 (Appropriateness of Health Care Examination) as follows:

Check ONLY ONE box below as applicable and provide date(s) as indicated for that box:

Injured employee/attorney notified insurance carrier of agreement to attend examination by carrier’s doctor on (mm/dd/yyyy)

Injured employee/attorney notified insurance carrier of non-agreement to attend examination by carrier’s doctor on (mm/dd/yyyy)

Sent to injured employee/attorney on (mm/dd/yyyy) and no reply received as of (mm/dd/yyyy)

• The insurance carrier will pay reasonable expenses incident to the examination of the injured employee.

• The selected doctor does not have a disqualifying association.

• I am authorized to act on behalf of the insurance carrier.

I understand that misrepresenting a workers’ compensation claim may result in enforcement action including administrative penalties and fines.

48. Signature of Adjuster or Authorized Insurance Carrier Representative

49. Date of Signature

50. Printed Name of Adjuster or Authorized Insurance Carrier Representative 51. Title of Person Signing

IX. INJURED EMPLOYEE AGREEMENT/NON-AGREEMENT

52. Complete this section and return a copy of this form to the insurance carrier ONLY if Section VII above has been completed.

I agree I do not agree - to attend the requested examination to determine whether health care I have received was appropriate.

NOTE: If you agree, you must attend the examination at the time and location scheduled. If you do not agree, the insurance carrier will submit the

request to TDI-DWC for review. If TDI-DWC approves the request, you will be issued an order to attend the examination.

53. Signature of Injured Employee or Injured Employee’s Attorney/Representative

For TDI-DWC Use Only

54. Printed Name of Injured Employee or Injured Employee’s Attorney/Representative

55. Date of Signature

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).

DWC022

DWC022 Rev. 07/11 Page 3 of 3

Information for the Injured Employee

For what purposes may a Required Medical Examination be requested?

DWC Form-022 Required Medical Examination - Request for Agreement / Request for Order is an insurance carrier’s request for you to be examined by a

doctor of the insurance carrier’s choice. This examination is called a Required Medical Examination, or RME.

• Request for Order (Evaluation of Designated Doctor Determination): If you have been examined by a Designated Doctor, the

insurance carrier may ask TDI-DWC to order you to attend an RME to address the same issue(s) the Designated Doctor addressed.

• Request for Agreement/Order (Appropriateness of Health Care Received): The insurance carrier may use the form to request your

agreement to attend an RME to determine whether health care you have received was appropriate. You have 15 days from the date the

carrier sent the request to you to complete Section IX. INJURED EMPLOYEE AGREEMENT/NON-AGREEMENT and return the

form to the insurance carrier. You should keep a copy for your records. If you do not agree to attend the RME, the insurance

carrier may ask TDI-DWC to order you to attend.

Exception for Network Claims: If you received medical benefits through a certified workers’ compensation health care network, the insurance

carrier is not

permitted to request an RME on the appropriateness of health care received.

Exception for Certain Political Subdivision Claims: If you received medical benefits 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, the insurance carrier is not

permitted to request an RME unless the RME is necessary to resolve a question relating to the entitlement to

or amount of income benefits.

How often can a Required Medical Examination be performed?

An RME to determine appropriateness of health care received may not be performed more than once every 180 days. Examinations to

evaluate a Designated Doctor determination may be performed more frequently. After you have received Supplemental Income Benefits for

eight quarters, an RME to evaluate a Designated Doctor determination regarding your ability to return-to-work may be performed no more than

once per year.

What will TDI-DWC do?

Within 7 days of receiving the insurance carrier’s request for an RME, TDI-DWC will approve or deny the request.

If TDI-DWC approves the insurance carrier’s request or you agree to attend the RME, TDI-DWC will issue an order requiring you to attend.

NOTE: If the request is approved, your failure to attend the scheduled RME may be considered an administrative violation and

may result in suspension of temporary income benefits, if applicable. You may request that your treating doctor attend the RME.

If TDI-DWC denies the insurance carrier’s request, you will receive a copy of the denial order. In that case you will not be required to attend the RME.

Can the RME appointment be rescheduled?

If you cannot attend an RME, you must contact the doctor’s office to reschedule the examination at least 24 hours in advance. The

rescheduled appointment must be no later than 7 days after the original appointment unless you and the doctor agree on a different date that

is no later than 30 days after the original appointment.

Questions / Information Regarding Travel Reimbursement

If you have questions regarding this form, need to request an accommodation under Title II of the Americans with Disabilities Act (ADA), or

need information about reimbursement of travel expenses, contact TDI-DWC by calling (800) 252-7031. To request travel reimbursement, you

must use the DWC-Form 048 Request for Travel Reimbursement which is available at

http://www.tdi.texas.gov/forms/formlisting.html.

Instructions for the Insurance Carrier

RME regarding Evaluation of Designated Doctor Determination

• After completing Sections I, II, and III, complete Sections IV, V and VI regarding an Evaluation of Designated Doctor Determination RME.

• Check the applicable box(es) in Section V, Box 29 to describe the reason(s) for the examination.

• Fax the request to TDI-DWC at (512) 804-4378.

RME regarding Appropriateness of Health Care Received

•

After completing Sections I, II, and III, complete Section VII regarding an Appropriateness of Health Care Received RME.

•

Attempt to obtain agreement by sending the form to the injured employee and the injured employee’s attorney or representative, if any.

•

Upon obtaining the employee’s answer in writing or by telephone or after 15 days with no response, complete Section VIII. In this section you must

indicate whether the injured employee agreed, refused to agree, or failed to respond to the request.

• Fax the request to TDI-DWC at (512) 804-4378.

➤ PDF File

Form Specifications

Fact Name	Fact Details
Form Purpose	The Texas DWC022 form is used for requesting a Required Medical Examination (RME) related to workers' compensation claims.
Governing Law	This form is governed by the Texas Labor Code, particularly §408.004 and §504.053.
Employee Information	Section I collects essential details about the employee, including name, Social Security number, and contact information.
Employer Details	Section II requires information about the employer at the time of the injury, such as the employer's name and address.
Insurance Carrier Info	Section III gathers information about the insurance carrier, including the adjuster's name and contact details.
Examination Purpose	Sections IV and V specify the purpose of the examination, which may include evaluating medical improvement or determining the appropriateness of care received.
Travel Requirements	If the employee's address and examination location are over 75 miles apart, an explanation must be provided in the form.
Certification	The insurance carrier must certify the accuracy of the information provided and ensure compliance with the Texas Labor Code.

Texas Dwc022: Usage Guidelines

Filling out the Texas DWC022 form is a straightforward process, but it requires attention to detail. This form is essential for requesting a Required Medical Examination (RME) related to workers' compensation claims. Follow these steps to ensure you complete it accurately.

Begin with Section I: Employee/Employee’s Attorney Information. Fill in the employee's full name, Social Security number, address, and telephone numbers. Also, include the date of injury and, if applicable, the attorney's name and address.
Move to Section II: Employer Information. Enter the employer's name and address at the time of the injury.
Proceed to Section III: Insurance Carrier Information. Provide the insurance carrier's name, address, adjuster's name, email, telephone number, fax number, and license number.
In Section IV: Examination Information, fill in the examining RME doctor's name, mailing address, license number, and telephone number. Specify the examination location and date/time of the appointment. Answer the questions about travel distance and health care networks as applicable.
In Section V: Purpose of Examination, include the designated doctor's name, the date of the designated doctor's examination, and check all relevant issues that need addressing.
Complete Section VI: Insurance Carrier Certification. Sign and print the name of the adjuster or authorized representative, include their title, and date the signature.
If you are completing Section VII for the Appropriateness of Health Care Received, repeat the information for the examining RME doctor and include the date of the prior examination and prior examining doctor's name.
In Section VIII, certify the information again, indicating whether the injured employee agreed or disagreed to attend the examination.
Finally, if Section VII was completed, fill out Section IX: Injured Employee Agreement/Non-Agreement. The injured employee or their representative must sign and date this section.

Once the form is filled out, make sure to keep a copy for your records. Submit the completed form to the appropriate parties as directed. This process is crucial for moving forward with any required medical evaluations related to the workers' compensation claim.

Your Questions, Answered

What is the Texas DWC022 form used for?

The Texas DWC022 form is used by insurance carriers to request a Required Medical Examination (RME) for an injured employee. There are two main purposes for this form. First, it can be used to evaluate a determination made by a Designated Doctor regarding the employee's medical condition. Second, it can be used to assess whether the health care received by the employee was appropriate. The form must be filled out completely and accurately to ensure the request is processed smoothly.

How often can a Required Medical Examination be performed?

An RME to determine the appropriateness of health care can be performed no more than once every 180 days. However, examinations to evaluate a Designated Doctor’s determination may occur more frequently. If the employee has received Supplemental Income Benefits for eight quarters, the RME regarding their ability to return to work can be conducted no more than once a year.

What happens after the insurance carrier submits the DWC022 form?

Once the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) receives the insurance carrier’s request for an RME, they will review it within 7 days. TDI-DWC will either approve or deny the request. If approved, an order will be issued requiring the employee to attend the examination. If denied, the employee will receive a copy of the denial order, and they will not be required to attend the RME.

Can the RME appointment be rescheduled?

If an employee cannot attend the scheduled RME, they must contact the doctor's office at least 24 hours in advance to reschedule. The new appointment should take place no later than 7 days after the original date. If more time is needed, the employee and the doctor can agree on a different date, but it must be within 30 days of the original appointment.

What should an employee do if they disagree with the RME?

If an employee does not agree to attend the RME, they must complete Section IX of the DWC022 form and return it to the insurance carrier. They have 15 days from the date of the request to respond. If the employee refuses to attend, the insurance carrier may still ask TDI-DWC to issue an order requiring attendance at the examination.

How can employees get information about travel reimbursement for the RME?

Employees can contact the TDI-DWC at (800) 252-7031 for questions about the DWC022 form, accommodations under the Americans with Disabilities Act, or travel reimbursement. To request reimbursement for travel expenses, employees must use the DWC-Form 048, which is available on the TDI website.

Common mistakes

Missing Information: Failing to fill out all required fields can lead to delays. Each section must be completed accurately.
Incorrect Dates: Entering the wrong date of injury or appointment can cause confusion. Always double-check these details.
Wrong Social Security Number: Providing an incorrect Social Security number can complicate the claim process. Ensure this number is accurate.
Inaccurate Contact Information: Listing outdated or incorrect addresses and phone numbers can hinder communication. Verify all contact details.
Neglecting to Sign: Forgetting to sign the form can render it invalid. Always ensure that the required signatures are present.
Not Providing Explanations: If the employee's address and examination location are over 75 miles apart, a clear explanation is necessary. Failing to provide this can lead to rejection.
Ignoring Deadlines: Submitting the form after the required deadline can result in complications. Be mindful of all timelines.
Incomplete Certification: The insurance carrier's certification must be complete and accurate. Omitting necessary details can cause issues.
Overlooking Network Claims: If medical benefits are through a certified network, be aware that an RME request may not be appropriate. Understanding this is crucial.

Documents used along the form

The Texas DWC022 form is a crucial document in the workers' compensation process, particularly for managing Required Medical Examinations (RMEs). However, several other forms and documents often accompany this form to ensure a comprehensive approach to handling claims and examinations. Below is a list of these related documents, each serving a specific purpose in the process.

DWC Form-073: This form is used to assess an employee's ability to return to work. It provides information regarding the employee's medical condition and the extent of their disability, helping to determine whether they can resume their previous job or require modifications.
DWC Form-048: This is the Request for Travel Reimbursement form. Injured employees can use it to seek reimbursement for travel expenses incurred while attending medical examinations or treatments related to their workers' compensation claim.
DWC Form-041: Known as the Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease, this document initiates the claims process. Employees complete this form to formally report their injury and seek benefits.
DWC Form-005: This form is the Employer's First Report of Injury or Illness. Employers are required to complete this document when an employee is injured at work, providing essential details about the incident and the employee's condition.
DWC Form-006: This is the Notice of Injury to Employees. It informs employees of their rights and responsibilities regarding workers' compensation, ensuring they understand the process following an injury.
DWC Form-007: The Notice of Change in Condition form is used to report any changes in the employee's medical condition or work status. This helps keep all parties informed and facilitates timely adjustments to the claim.
DWC Form-031: This form is the Request for Designated Doctor Examination. It is utilized when a designated doctor needs to evaluate the employee's condition, particularly in cases of disputes regarding the extent of injury or recovery.

Each of these forms plays a vital role in the workers' compensation system in Texas. Understanding their purposes can help injured employees navigate the complexities of their claims and ensure they receive the benefits to which they are entitled. Properly completing and submitting these forms can significantly influence the outcome of a claim, making it essential to approach each step with care and attention.

Similar forms

The Texas DWC022 form, which is a request for a Required Medical Examination (RME), shares similarities with several other important documents in the realm of workers' compensation and medical evaluations. Below are five documents that have comparable purposes or functions:

DWC Form-073: Ability to Return to Work - This form assesses whether an employee is capable of returning to their job after an injury. Like the DWC022, it requires detailed information about the employee's medical condition and the context of their injury, focusing on their readiness to resume work duties.
DWC Form-048: Request for Travel Reimbursement - This document is used to claim reimbursement for travel expenses incurred while attending medical examinations related to workers' compensation claims. Similar to the DWC022, it requires specific details about the employee's travel and the medical appointments they are attending.
DWC Form-069: Employee's Claim for Compensation - This form initiates a claim for workers' compensation benefits. It is akin to the DWC022 in that it gathers essential information about the employee, their injury, and the circumstances surrounding their claim, serving as a foundational document in the workers' compensation process.
DWC Form-041: Designated Doctor Examination Report - This report is generated after a designated doctor evaluates an injured worker. It provides findings that may influence the outcome of claims, similar to how the DWC022 requests a medical examination to address specific issues related to the employee's condition.
DWC Form-032: Request for Change of Treating Doctor - This form is submitted when an injured worker seeks to change their treating physician. Like the DWC022, it involves the assessment of medical care and treatment, ensuring that the injured worker receives appropriate care aligned with their recovery needs.

Dos and Don'ts

When filling out the Texas DWC022 form, there are several important dos and don’ts to keep in mind. Following these guidelines can help ensure that the process goes smoothly.

Do provide accurate information for all required fields, including names, addresses, and dates.
Do double-check the employee’s Social Security number to avoid any errors.
Do ensure that the insurance carrier’s details are complete and correct.
Do include the date and time of the examination clearly.
Do keep a copy of the completed form for your records.
Don’t leave any required fields blank; incomplete forms may cause delays.
Don’t provide inaccurate or misleading information, as this could lead to penalties.
Don’t forget to sign and date the form before submission.
Don’t submit the form without confirming that all necessary sections are completed.

Misconceptions

Misconception 1: The DWC022 form is only for employees with severe injuries.

This is not true. The DWC022 form can be used for any employee who is involved in a workers' compensation claim, regardless of the severity of their injury. It is meant to facilitate required medical examinations for various situations.

Misconception 2: Completing the form guarantees that the insurance carrier will approve the examination.

While the form is necessary to request an examination, it does not guarantee approval. The Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) must review the request and can either approve or deny it.

Misconception 3: Employees have unlimited time to respond to the form.

In fact, employees must respond within 15 days of receiving the request. If they do not respond, the insurance carrier may proceed with further actions, including requesting an order from TDI-DWC.

Misconception 4: Employees can ignore the examination if they do not agree with it.

Ignoring the examination is not an option. If an employee does not agree to attend, the insurance carrier may still seek an order from TDI-DWC requiring attendance. Failure to comply could lead to penalties.

Misconception 5: The DWC022 form is only relevant for medical examinations related to physical injuries.

This form can be used for various types of evaluations, including those related to mental health issues that arise from work-related incidents. It addresses the overall appropriateness of care received.

Misconception 6: The form must be filled out perfectly to be valid.

While accuracy is important, minor errors may not invalidate the form. However, all essential information should be completed to avoid delays in processing the request.

Key takeaways

Accurate Completion is Essential: Fill out all sections of the DWC022 form completely and accurately. Missing information can delay the process and may affect the outcome of the examination.
Timeliness Matters: The injured employee has 15 days to respond to the request for a Required Medical Examination (RME). It's crucial to return the form promptly to avoid complications.
Understand the Purpose: The DWC022 form serves two main purposes: to evaluate a Designated Doctor's determination and to assess the appropriateness of health care received. Knowing the reason for the RME helps in preparing for the examination.
Travel Considerations: If the examination location is more than 75 miles from the employee's address, an explanation is required. Additionally, the employee may be eligible for travel reimbursement, so keeping records of travel expenses is advisable.