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Blank Texas Dwc069 Form

The Texas DWC069 form is a Report of Medical Evaluation required by the Texas Department of Insurance, Division of Workers’ Compensation. This form is used to document a medical evaluation related to workers' compensation claims, specifically addressing the injured employee's maximum medical improvement (MMI) and any permanent impairment resulting from their injury. Proper completion and timely submission of this form are essential for ensuring that injured employees receive appropriate medical benefits and support.

Outline

The Texas DWC069 form, officially known as the Report of Medical Evaluation, plays a crucial role in the workers' compensation process in Texas. This form is primarily used to document the medical evaluation of an injured employee, specifically focusing on 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, date of injury, and social security number, as well as the credentials of the certifying doctor. The form outlines the doctor's role in the evaluation process, specifying whether they are acting as a treating doctor, a designated doctor, or a doctor selected by the treating doctor. Additionally, the DWC069 form mandates the doctor to assess and certify whether the employee has reached either Clinical or Statutory MMI, providing a clear distinction between the two. If the employee has reached MMI, the doctor must also evaluate and document any permanent impairment, including the percentage of impairment, based on objective medical findings. The form emphasizes the importance of accurate and honest reporting, as misrepresentation can have serious legal consequences. Ultimately, the DWC069 form serves as a vital tool for ensuring that injured workers receive the appropriate medical evaluations and benefits they are entitled to under Texas law.

Sample - Texas Dwc069 Form

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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DWC069

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	Treating Doctor
		Insurance Carrier	DWC
			DWC
Designated Doctor	fax or e-mail		fax or e-mail

Treating Doctor			fax or e-mail unless recipient has
Doctor Selected by Treating Doctor		fax or e-mail	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.

DWC069 Rev. 01/15

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DWC069

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).

DWC069 Rev. 01/15

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Form Information

Fact Name	Details
Purpose	The DWC069 form is used to report medical evaluations related to workers' compensation claims in Texas.
Governing Laws	This form is governed by the Texas Labor Code, specifically §408.104, and 28 Texas Administrative Code §130.1.
Filing Requirements	The form must be filed within seven working days after the examination or receipt of necessary medical information.
Authorized Signatories	Only certain medical professionals, such as treating doctors or designated doctors, are authorized to complete and submit this form.

Detailed Guide for Filling Out Texas Dwc069

Completing the Texas DWC069 form is an important step in the workers’ compensation process. This form, known as the Report of Medical Evaluation, requires specific information about the injured employee, the evaluating doctor, and the medical status of the employee. Once filled out, it must be submitted to the appropriate parties, including the insurance carrier and the Division of Workers’ Compensation.

Gather Necessary Information: Collect all required information about the injured employee, including their name, date of injury, and Social Security number.
Fill in General Information: Complete the sections for the Workers’ Compensation Insurance Carrier, Employer’s Name, and addresses for both the employer and the employee.
Document the Certifying Doctor's Information: Enter the name, license type, license number, jurisdiction, phone, fax numbers, and address of the certifying doctor.
Indicate the Doctor’s Role: Specify the role of the doctor in the evaluation process by checking the appropriate box.
Record Medical Status Information: Fill in the date of the exam and diagnosis codes. Indicate whether the employee has reached Clinical or Statutory Maximum Medical Improvement (MMI) and provide the relevant date.
Assess Permanent Impairment: If applicable, indicate whether the employee has permanent impairment and provide the percentage of impairment, if any.
Certify the Report: The certifying doctor must sign and date the report, ensuring that all information is accurate and complete.
Include Treating Doctor’s Agreement or Disagreement: If applicable, the treating doctor should indicate their agreement or disagreement with the certifying doctor’s findings and provide their signature and date.
Submit the Form: Send the completed form to the insurance carrier, treating doctor, DWC, injured employee, and any representative of the injured employee as required.

After completing these steps, ensure that all documentation is retained for your records. Proper submission of the DWC069 form is crucial for the continuation of benefits and the management of the workers' compensation claim.

Obtain Answers on Texas Dwc069

What is the Texas DWC069 form?
The Texas DWC069 form is the Report of Medical Evaluation used in workers' compensation claims. It is completed by a doctor to certify whether an injured employee has reached Maximum Medical Improvement (MMI) and to assess any permanent impairment resulting from the injury.
Who can complete the DWC069 form?
Only certain doctors can fill out the DWC069 form. These include:
- Treating Doctor: The primary doctor responsible for the employee's injury-related care.
- Doctor Selected by Treating Doctor: A doctor chosen by the treating doctor to evaluate MMI and permanent impairment.
- Designated Doctor: A doctor appointed by the Texas Department of Insurance to resolve questions about MMI or impairment.
- Insurance Carrier-Selected RME Doctor: A doctor selected by the insurance carrier, but only if approved by DWC.
When must the DWC069 form be filed?
The form must be filed no later than the seventh working day after the examination if the employee has reached MMI. If the employee has not reached MMI, only a Designated Doctor is required to file the form within that timeframe.
Where should the DWC069 form be submitted?
The completed form should be sent to:
- The insurance carrier
- The treating doctor (if applicable)
- The Texas Department of Insurance, Division of Workers’ Compensation (DWC)
- The injured employee
- The injured employee's representative (if any)
Submission can be done via fax or electronic transmission unless otherwise specified.
What happens if I disagree with the doctor's evaluation?
If you disagree with the MMI certification or the permanent impairment rating, you can dispute it. This must be done within 90 days of receiving the written notice. You can request a designated doctor or a Benefit Review Conference to address your concerns.
What documentation must the certifying doctor keep?
The certifying doctor must maintain the original report and any related narratives. They should also document the date of the examination, when medical records were received, and the details of how reports were transmitted.
Is there a penalty for misrepresenting information on the DWC069 form?
Yes, misrepresentation on the form is considered a crime and can lead to fines or imprisonment. It can also result in the nullification of the report.
Where can I find more information about the DWC069 form?
For detailed information, you can refer to the Texas Administrative Code sections 130.1 through 130.4 and 130.6. The full text of these rules is available on the Texas Department of Insurance website at www.tdi.texas.gov/wc/rules/index.html.

Common mistakes

Filling out the Texas DWC069 form can be straightforward, but many people make mistakes that can lead to complications. One common error is failing to provide complete information about the injured employee. This includes missing details such as the employee’s full name, social security number, or contact information. Omitting even one piece of information can delay the processing of the claim.

Another frequent mistake is entering incorrect dates. The date of injury and the date of the medical evaluation are critical. If these dates are inaccurate, it can create confusion regarding the timeline of the case. Always double-check the dates before submitting the form.

People often overlook the importance of the certifying doctor's role. It's crucial to ensure that the doctor filling out the form is authorized to evaluate Maximum Medical Improvement (MMI) and impairment ratings. If the doctor is not properly designated, the report may be deemed invalid, causing further delays.

Additionally, many individuals forget to include necessary documentation. When certifying MMI, the doctor must attach a narrative that supports their findings. Without this documentation, the certification may not hold up during reviews or disputes.

Another common pitfall is misinterpreting the definitions of Clinical and Statutory MMI. Misunderstanding these terms can lead to incorrect certifications. It's essential to grasp these definitions clearly to ensure accurate reporting.

Some people also fail to sign the form. A missing signature can render the entire submission invalid. Make sure to check that all required signatures are present before sending the form off.

Finally, many submitters forget to keep a copy of the completed form and any attached documents. Retaining a copy is crucial for future reference, especially if any disputes arise later. Keeping organized records can save a lot of time and hassle down the road.

Documents used along the form

The Texas DWC069 form, known as the Report of Medical Evaluation, is crucial for documenting an injured employee's medical status in the workers' compensation system. Alongside this form, several other documents may be necessary to ensure a comprehensive evaluation and processing of claims. Below is a list of common forms that often accompany the DWC069.

DWC Form-041: This form is used for reporting the injury and provides essential details about the incident. It serves as the initial claim form for workers' compensation.
DWC Form-073: This document is used to request a Benefit Review Conference (BRC) when there is a dispute regarding the claim. It helps facilitate discussions between the injured employee and the insurance carrier.
DWC Form-045: This is the Employee’s Claim for Compensation for a Work-Related Injury form. It allows employees to formally initiate a claim for benefits due to their injury.
DWC Form-032: This form is utilized for the Notification of Maximum Medical Improvement (MMI). It informs all parties involved when the injured employee has reached MMI.
DWC Form-053: This is the Designated Doctor Examination Report. It documents the findings from examinations conducted by designated doctors, particularly in disputed cases.
DWC Form-042: This form is used to request a hearing regarding a dispute in the workers' compensation claim process. It allows for further legal proceedings if necessary.
DWC Form-067: This is the Request for Medical Records form. It is used to obtain medical documentation that supports the employee's claim and ongoing treatment.
DWC Form-069 Narrative: Accompanying the DWC069, this narrative provides additional context and details regarding the medical evaluation, including treatment history and prognosis.
DWC Form-076: This form is used for the Employee’s Reimbursement Request for Travel Expenses. It allows employees to claim reimbursement for travel costs incurred while attending medical appointments related to their injury.
DWC Form-007: This is the Notice of Injury or Illness form. It serves as a formal notification to the employer regarding the employee's injury or illness.

These forms and documents collectively support the workers' compensation process, ensuring that all necessary information is available for claims review and resolution. Proper completion and timely submission of these documents can significantly impact the outcome of a claim.

Similar forms

The Texas DWC069 form, known as the Report of Medical Evaluation, serves a crucial role in the workers' compensation process. Several other documents share similarities with this form, primarily in their purpose of evaluating medical conditions and determining benefits. Here’s a look at eight documents that are similar to the DWC069 form:

Texas DWC Form-073: This form is used for the Designated Doctor Examination Report. Like the DWC069, it assesses an employee's Maximum Medical Improvement (MMI) and permanent impairment, but it is specifically for cases where a designated doctor is involved.
Texas DWC Form-041: Known as the Employee’s Notice of Injury or Occupational Disease, this form reports the injury or disease. While it does not evaluate medical conditions, it initiates the process that leads to the need for forms like the DWC069.
Texas DWC Form-069A: This is the Report of Medical Evaluation for Non-Subscriber Claims. Similar to the DWC069, it assesses medical evaluations but is tailored for claims outside the traditional workers' compensation system.
Texas DWC Form-052: This form is the Request for Designated Doctor Examination. It is similar in that it requests an evaluation to determine MMI and impairment, guiding the process for the DWC069 to be filed afterward.
Texas DWC Form-073A: This is the Designated Doctor Examination Report for Impairment Ratings. It evaluates the same aspects as the DWC069 but focuses specifically on impairment ratings assigned by designated doctors.
Texas DWC Form-040: The Claimant’s Report of Injury is used to document the details of the injury. While it doesn’t evaluate medical conditions, it lays the groundwork for the subsequent medical evaluations captured in the DWC069.
Texas DWC Form-070: This is the Report of Medical Evaluation for Impairment Ratings. It serves a similar purpose to the DWC069 but is specifically focused on impairment ratings without the broader context of MMI.
Texas DWC Form-061: This form is used for the Employee's Claim for Compensation for a Work-Related Injury. It initiates the claim process, similar to how the DWC069 provides critical medical information to support that claim.

Each of these documents plays a unique role in the workers' compensation process, yet they share the common goal of ensuring that injured employees receive the medical evaluations and benefits they deserve.

Dos and Don'ts

When filling out the Texas DWC069 form, attention to detail is crucial. Here are ten essential dos and don’ts to guide you through the process.

Do ensure all required fields are completed accurately.
Do provide your certification date and the date of the medical evaluation.
Do include the correct diagnosis codes for the employee's condition.
Do clearly indicate whether the employee has reached Maximum Medical Improvement (MMI).
Do attach all necessary documentation to support your findings.

Don't leave any fields blank, as this may delay processing.
Don't use prospective dates for MMI; ensure dates are accurate and retrospective.
Don't forget to sign and date the certification section of the form.
Don't submit the form without verifying that all information is correct.
Don't assume that verbal communication is sufficient; always file the form as required.

By following these guidelines, you can help ensure a smoother process when submitting the DWC069 form. Accuracy and completeness are key to facilitating the workers' compensation process in Texas.

Misconceptions

Misconception 1: The DWC069 form can be completed by any doctor.

Only specific doctors are authorized to fill out the DWC069 form. These include the treating doctor, a doctor selected by the treating doctor, a designated doctor chosen by the DWC, and an insurance carrier-selected RME doctor. If a doctor is not in one of these roles, their certification will be invalid.

Misconception 2: Completing the DWC069 form guarantees that the employee will receive benefits.

Filing the DWC069 form does not automatically ensure that an employee will receive medical benefits. The form serves to report the medical evaluation, but the determination of benefits depends on various factors, including the findings of MMI and impairment.

Misconception 3: The DWC069 form can be submitted at any time after the medical evaluation.

There are strict deadlines for submitting the DWC069 form. If an employee has reached Maximum Medical Improvement (MMI), the form must be filed no later than the seventh working day after the examination or after receiving all necessary medical information. Failure to meet this deadline can result in complications for the claim.

Misconception 4: A finding of no impairment means the employee has a 0% impairment rating.

A finding of no impairment does not equate to a 0% impairment rating. A doctor can only assign an impairment rating, including a 0% rating, if they performed the necessary examination and testing as per the AMA Guides. Therefore, a finding of no impairment should be clearly documented and does not imply a numerical rating.

Key takeaways

Filling out the Texas DWC069 form accurately is crucial for both injured employees and healthcare providers involved in workers' compensation claims. Here are key takeaways to keep in mind:

Complete all required fields: Ensure that all sections of the form, including general information about the injured employee and the certifying doctor, are filled out completely.
Understand the doctor's role: Only authorized doctors can evaluate Maximum Medical Improvement (MMI) and file this report. This includes treating doctors and designated doctors.
Certification of MMI: The doctor must indicate whether the employee has reached either Clinical or Statutory MMI, providing the appropriate date and documentation.
Permanent impairment assessment: If the employee has reached MMI, the doctor must determine if there is any permanent impairment resulting from the injury, supported by objective medical evidence.
File in a timely manner: The DWC069 form must be submitted no later than seven working days after the examination date or after receiving necessary medical records.
Maintain documentation: The certifying doctor should keep a copy of the report and any supporting documentation, including dates of examinations and communications regarding the report.
Dispute process: If an injured employee disagrees with the certification of MMI or the impairment rating, they must file a dispute within 90 days of receiving the notice.
Filing method: Submit the form via facsimile or electronic transmission to the appropriate parties, including the insurance carrier and the Texas Department of Insurance.

These takeaways will help ensure compliance with the requirements of the Texas workers' compensation system and facilitate a smoother process for all parties involved.