The Texas DWC069 form is a Report of Medical Evaluation used in the workers' compensation system. This form is essential for certifying an injured employee's Maximum Medical Improvement (MMI) and any permanent impairment resulting from their injury. To ensure proper processing, complete the form accurately and submit it by clicking the button below.
The Texas DWC069 form, officially known as the Report of Medical Evaluation, serves a crucial role in the state's workers' compensation system. This form is primarily utilized to document a medical evaluation of an injured employee, specifically addressing their Maximum Medical Improvement (MMI) status and any permanent impairment resulting from their injury. It requires detailed information about the injured employee, including their name, Social Security number, and the specifics of their injury, such as the date of occurrence and the employer's details. The form also outlines the certifying doctor's credentials, ensuring that only qualified medical professionals—such as treating doctors or designated doctors—can certify MMI or assign impairment ratings. This is vital because the determination of MMI can significantly affect an employee's eligibility for ongoing medical benefits. Additionally, the form includes sections for the doctor to indicate whether the employee has reached either Clinical or Statutory MMI and to provide a percentage rating for any permanent impairment, if applicable. Furthermore, the form emphasizes the importance of accuracy and compliance with Texas labor laws, as misrepresentations can lead to serious legal repercussions. In short, the DWC069 form is a key document that facilitates the fair assessment of medical conditions arising from workplace injuries, impacting both the injured employees and the insurance carriers involved.
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
Report of Medical Evaluation
DWC069
Complete if known:
DWC Claim #
Carrier Claim #
I. GENERAL INFORMATION
4. Injured Employee's Name (First, Middle, Last)
1.
Workers’ Compensation Insurance Carrier
5.
Date of Injury
6. Social Security Number
2.
Employer’s Name
7. Employee's Phone Number
3.
Employer’s Address (Street or PO Box, City State Zip)
8.
Employee’s Address (Street or PO Box, City State Zip)
9.Certifying Doctor's Name and License Type
10.Certifying Doctor's License Number and Jurisdiction
11.Certifying Doctor’s Phone and Fax Numbers
(Ph)(Fax)
12.Certifying Doctor’s Address (Street or PO Box, City State Zip)
II. DOCTOR’S ROLE
13.Indicate which role you are serving in the claim in performing this evaluation. Only a doctor serving in one of the following roles is authorized to evaluate MMI/impairment and file this report [28 Texas Administrative Code (TAC) §130.1 governs such authorization]:
Treating Doctor
Doctor selected by Treating Doctor acting in place of the Treating Doctor
Designated Doctor selected by DWC
Insurance Carrier-selected RME Doctor approved by DWC to evaluate MMI and/or permanent impairment after a Designated Doctor examination NOTE: If you are not authorized by 28 TAC §130.1 to file this report, you will not be paid for this report or the MMI/impairment examination.
III. MEDICAL STATUS INFORMATION
14. Date of Exam
15. Diagnosis Codes
____ / ____ / ________
16. Indicate whether the
employee has reached Clinical or Statutory MMI based upon the following definitions:
Clinical Maximum Medical Improvement (Clinical MMI) is the earliest date after which, based upon reasonable medical probability, further material recovery from or lasting improvement to an injury can no longer reasonably be anticipated.
Statutory MMI is the later of: (1) the end of the 104th week after the date that temporary income benefits (TIBs) began to accrue; or
(2)the date to which MMI was extended by DWC pursuant to Texas Labor Code §408.104.
a) Yes, I certify that the employee reached STATUTORY / CLINICAL (mark one) MMI on ____ / ____ / ________
(may not be a prospective date) and have included documentation relating to this certification in the attached narrative. - OR -
b) No, I certify that the employee has NOT reached MMI but is expected to reach MMI on or about ____ / ____ / ________
The reason the employee has not reached MMI is documented in the attached narrative.
NOTE: The fact that an employee reaches either Clinical MMI or Statutory MMI does not signify that the employee is no longer entitled to medical benefits.
IV. PERMANENT IMPAIRMENT
17. If the employee has reached MMI, indicate whether the employee has permanent impairment as a result of the compensable injury.
“Impairment” means any anatomic or functional abnormality or loss existing after MMI that results from a compensable injury and is reasonably presumed to be permanent. The finding that impairment exists must be made based upon objective clinical or laboratory findings meaning a medical finding of impairment resulting from a compensable injury, based upon competent objective medical evidence that is independently confirmable by a doctor, including a designated doctor, without reliance on the subjective symptoms perceived by the employee.
a) I certify that the employee does not have any permanent impairment as a result of the compensable injury. - OR -
b) I certify that the employee has permanent impairment as a result of the compensable injury. The amount of permanent impairment is _____%, which was determined in accordance with the requirements of the Texas Labor Code and Texas Administrative Code. The attached narrative provides explanation and documentation used for the calculation of the impairment rating assigned using the appropriate tables, figures, or worksheets from the following
edition of the Guides to the Evaluation of Permanent Impairment published by the American Medical Association (AMA): third edition, second printing, February 1989 - OR -
fourth edition, 1st, 2nd, 3rd, or 4th printing, including corrections and changes issued by the AMA prior to May 16, 2000.
NOTE: A finding of no impairment is not equivalent to a 0% impairment rating. A doctor can only assign an impairment rating, including a 0% rating, if the doctor performed the examination and testing required by the AMA Guides.
V. DOCTOR’S CERTIFICATION
18.I HEREBY CERTIFY THAT THIS REPORT OF MEDICAL EVALUATION is complete and accurate and complies with the Texas Labor Code and applicable rules. If an impairment rating has been assigned, I certify that I have completed the required training and testing and have a current certification by DWC to assign impairment ratings in the Texas workers' compensation system or have received specific permission by DWC to certify MMI and assign an impairment rating. I understand that making a misrepresentation about a workers’ compensation claim or myself is a crime that can result in fines and/or imprisonment and nullification of this report.
Signature of Certifying Doctor: _________________________________________________
Date of Certification: __________________
VI. TREATING DOCTOR’S AGREEMENT OR DISAGREEMENT WITH ANOTHER DOCTOR’S CERTIFICATION
19.
Treating Doctor's Name and License Type
22.
I AGREE / I DISAGREE with the certifying doctor’s certification of MMI.
20.
Treating Doctor's License Number and Jurisdiction
23.
I AGREE / I DISAGREE with the certifying doctor’s finding of no impairment. - OR -
21.
Treating Doctor’s Phone and Fax Numbers
I AGREE / I DISAGREE with the impairment rating assigned by the certifying doctor.
(Ph)
(Fax)
24.I understand that making a misrepresentation about a workers’ compensation claim is a crime that can result in fines and/or imprisonment.
Signature of Treating Doctor: __________________________________________________
Date: _____________________________
DWC069 Rev. 01/15
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Frequently Asked Questions
Report of Medical Evaluation (DWC Form-069)
INSTRUCTIONS FOR DOCTORS:
Who can file the DWC Form-069?
Treating Doctor: Doctor chosen by the employee who is primarily responsible for employee's injury-related health care.
Doctor Selected by Treating Doctor: Doctor selected by the treating doctor to evaluate permanent impairment and Maximum Medical Improvement (MMI). This doctor acts in the place of the treating doctor. Such a doctor must be selected if the treating doctor is not authorized to certify MMI or assign an impairment rating in those cases in which the employee has permanent impairment. An authorized treating doctor may also choose to select another doctor to perform the evaluation/certification.
Designated Doctor: Doctor selected by the Texas Department of Insurance, Division of Workers’ Compensation (DWC) to resolve a question over MMI or permanent impairment.
Insurance Carrier-Selected RME Doctor: Doctor selected by the insurance carrier to evaluate MMI and/or permanent impairment. An insurance carrier-selected Required Medical Examination (RME) Doctor is only authorized to certify MMI, evaluate permanent impairment, and assign an impairment rating when specifically approved by DWC prior to the examination and only after a designated doctor has completed the same.
AUTHORIZATION: In addition to the requirement of acting in an eligible role, 28 Texas Administrative Code §130.1 provides the following requirements:
Employee has permanent impairment: Only a doctor certified by DWC to assign impairment ratings or who receives specific
permission by exception granted by DWC is authorized to certify MMI and to assign an impairment rating.
Employee does not have permanent impairment: A doctor not certified or exempted from certification by DWC is only authorized to determine whether an employee has permanent impairment and, in the event that the employee has no impairment, certify MMI.
INVALID CERTIFICATION: Certification by a doctor who is not authorized is invalid.
Under what circumstances and when am I required to file the DWC Form-069?
If the employee has reached MMI, you must file the DWC Form-069 no later than the seventh working day after the later of: (a) date of the certifying examination; or (b) receipt of all medical information necessary to certify MMI. Only a Designated Doctor is subject to this requirement if the employee has not reached MMI.
Where do I file the form?
The DWC Form-069 and required narrative shall be filed with:
the insurance carrier;
the treating doctor (if a doctor other than the treating doctor files the report);
DWC;
injured employee; and
injured employee’s representative (if any).
The report must be filed by facsimile or electronic transmission unless an exception applies. The specific requirements are shown below. To file this form with DWC, fax to (512) 490-1047.
Insurance Carrier
DWC
Designated Doctor
fax or e-mail
fax or e-mail unless recipient has
Doctor Selected by Treating Doctor
not provided these numbers; then
Insurance Carrier-Selected RME Doctor
by other verifiable means
Injured Employee
Injured Employee’s Representative
fax or e-mail unless recipient has not provided these numbers; then by other verifiable means
Do I have to maintain documentation regarding the examination and report?
The certifying doctor must maintain the original copy of the report and narrative and documentation of the following:
date of the examination;
date any medical records necessary to make the certification of MMI were received, and from whom the medical records were received; and
date, addresses, and means of delivery that required reports were transmitted or mailed by the certifying doctor.
Where can I find more information about the Report of Medical Evaluation?
See 28 TAC §130.1 through §130.4 and §130.6 for the complete requirements regarding the filing of this report, including required documentation. The complete text of these rules is available on the Texas Department of Insurance website at www.tdi.texas.gov/wc/rules/index.html. If you have additional questions, call 1-800-372-7713, Option #3.
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IMPORTANT INFORMATION FOR INJURED EMPLOYEES:
What if I disagree with the doctor's certification of Maximum Medical Improvement (MMI) and/or permanent impairment rating for my workers' compensation claim?
If this is the first evaluation of your MMI and/or permanent impairment, you or your representative may dispute:
the certification of MMI; and/or
the assigned impairment rating.
To file the dispute, contact your local DWC field office or call 1-800-252-7031 to request:
the appointment of a designated doctor (DD), if one has not been appointed; or
a Benefit Review Conference (BRC).
Important Note: Your dispute must be filed within 90 days after the written notice is delivered to you or the certification of MMI and/or the assigned impairment rating may become final.
NOTE: With few exceptions, upon your request, you are entitled to be informed about the information DWC collects about you; receive and review the information (Government Code, §§552.021 and 552.023); and have DWC correct information that is incorrect (Government Code, §559.004).
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Filling out the Texas DWC069 form is an important step in the workers' compensation process. This report must be completed accurately to ensure that all necessary medical evaluations are documented properly. The following steps will guide you through the process of filling out the form effectively.
After completing the form, it is essential to file it with the appropriate parties, including the insurance carrier, treating doctor, and the Division of Workers’ Compensation. Timely submission will help ensure that the claim is processed smoothly. Remember to keep a copy for your records.
The Texas DWC069 form, also known as the Report of Medical Evaluation, is primarily used to document the medical evaluation of an injured employee within the Texas workers' compensation system. This form is completed by a qualified medical professional to certify whether the employee has reached Maximum Medical Improvement (MMI) and to assess any permanent impairment resulting from a workplace injury.
Only specific medical professionals can complete the DWC069 form. These include:
The DWC069 form must be filed within specific timeframes. If the employee has reached MMI, the form should be submitted no later than the seventh working day after:
For Designated Doctors, the filing requirement applies only if the employee has not reached MMI.
The completed DWC069 form must be filed with several parties, including:
Filing can typically be done via fax or electronic transmission, unless exceptions apply.
The certifying doctor is required to keep the original copy of the DWC069 form along with supporting documentation. This includes:
Maintaining this documentation is crucial for compliance and future reference.
If an injured employee disagrees with the MMI certification or the assigned impairment rating, they have the right to dispute it. This must be done within 90 days of receiving written notice of the certification. The employee can:
Timely action is essential, as failure to dispute within the specified period may result in the certification becoming final.
Failing to provide the correct DWC Claim # and Carrier Claim #. These numbers are essential for tracking the claim.
Not including the employee's full name as required. Ensure the first, middle, and last names are accurate.
Leaving out the date of injury. This date is critical for determining the timeline of the claim.
Incorrectly filling in the social security number. Double-check for accuracy to avoid processing delays.
Not specifying the certifying doctor's role in the evaluation. Clearly indicate whether the doctor is a treating doctor or designated doctor.
Failing to document the date of examination. This information is necessary for compliance with filing deadlines.
Using prospective dates when certifying MMI. The date must be in the past or present.
Not signing the form. The certifying doctor’s signature is required to validate the report.
The Texas DWC069 form, known as the Report of Medical Evaluation, plays a crucial role in the workers' compensation process. It is often accompanied by several other forms and documents that help ensure a comprehensive understanding of the injured employee's medical status and rights. Below are some commonly used documents that complement the DWC069 form.
These forms and documents work together to provide a complete picture of the workers' compensation claim process in Texas. Understanding their roles can help injured employees navigate their claims more effectively and ensure they receive the benefits they deserve.
The Texas DWC Form-069, known as the Report of Medical Evaluation, has similarities with the DWC Form-073, which is the Report of Medical Examination. Both forms are utilized in the workers' compensation system to document medical evaluations of injured employees. The DWC Form-073 also captures details about the employee's medical condition and the doctor's assessment of Maximum Medical Improvement (MMI) and permanent impairment. However, the DWC Form-073 is specifically designed for initial evaluations, while the DWC Form-069 is typically used for follow-up assessments or when a dispute arises regarding an employee's medical status.
Another document similar to the DWC Form-069 is the DWC Form-041, which is the Employee’s Claim for Compensation for a Work-Related Injury. This form serves to initiate a claim for workers' compensation benefits. While the DWC Form-041 focuses on the employee's account of the injury and their request for benefits, the DWC Form-069 provides a medical evaluation that supports or contradicts the claims made by the employee. Both forms are essential for processing a workers' compensation case, but they serve different purposes in the claims process.
The DWC Form-045, known as the Notice of Change of Treating Doctor, is another document with a related function. This form allows an employee to change their treating doctor within the workers' compensation system. While the DWC Form-069 is used to report on medical evaluations, the DWC Form-045 is focused on the administrative aspect of changing medical providers. Both forms involve communication between the employee, their medical provider, and the insurance carrier, but they address different stages of the claims process.
Similar to the DWC Form-069 is the DWC Form-032, which is the Request for Designated Doctor Examination. This form is used when there is a dispute regarding MMI or impairment ratings, prompting a designated doctor to evaluate the employee. Like the DWC Form-069, the DWC Form-032 plays a crucial role in resolving disputes in the workers' compensation process. However, the DWC Form-032 specifically requests an independent examination, while the DWC Form-069 reports findings from a medical evaluation already conducted.
The DWC Form-061, known as the Report of Injury, is another document that shares similarities with the DWC Form-069. This form is completed by the employer or the insurance carrier to report an injury to the Texas Department of Insurance. While the DWC Form-061 focuses on the details of the injury and the circumstances surrounding it, the DWC Form-069 is concerned with the medical evaluation of the injured employee. Both forms are integral to the workers' compensation process, providing necessary information to assess the claim.
The DWC Form-050, which is the Notice of Injury or Illness, also shares a purpose with the DWC Form-069. This form serves as a formal notification to the insurance carrier about an employee's injury. While the DWC Form-050 emphasizes the reporting of the incident, the DWC Form-069 provides a detailed medical assessment of the injury's impact on the employee's health. Both forms are essential for establishing a comprehensive understanding of the claim.
The DWC Form-070, known as the Medical Record Release, is another document that complements the DWC Form-069. This form allows for the sharing of medical records between the employee, their healthcare provider, and the insurance carrier. While the DWC Form-069 documents the findings of a medical evaluation, the DWC Form-070 facilitates access to the medical records that may support those findings. Both forms ensure that all relevant medical information is considered in the workers' compensation process.
Another related document is the DWC Form-069A, which is the Report of Medical Evaluation for Non-Subscriber Claims. This form is used when an employee is seeking medical evaluation outside of the traditional workers' compensation system. Similar to the DWC Form-069, it assesses the employee's medical status and any permanent impairment. However, the DWC Form-069A is tailored for non-subscriber claims, highlighting the differences in the claims process for employees covered by alternative insurance.
The DWC Form-064, or the Request for Medical Records, is also relevant in this context. This form is used to obtain medical records necessary for evaluating a claim. While the DWC Form-069 reports on a specific medical evaluation, the DWC Form-064 ensures that all relevant medical history is available for review. Both documents are crucial in making informed decisions regarding the employee's claim.
Lastly, the DWC Form-072, which is the Certification of Maximum Medical Improvement, is closely related to the DWC Form-069. This form is used to certify that an employee has reached MMI and is often completed by the same medical professionals who fill out the DWC Form-069. Both forms document the medical status of the employee, but the DWC Form-072 specifically focuses on the certification aspect, while the DWC Form-069 provides a broader evaluation of the employee's condition.
Misconceptions about the Texas DWC069 form can lead to confusion for injured employees and healthcare providers alike. Here are nine common misunderstandings:
Understanding these misconceptions can help clarify the importance of the DWC069 form and ensure that all parties involved follow the correct procedures.
Filling out the Texas DWC069 form is a critical step in the workers' compensation process. Here are five key takeaways to keep in mind: