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The Texas DWC022 form is a crucial document in the workers' compensation process, serving as a formal request for a Required Medical Examination (RME) by the insurance carrier. This form outlines important details about the injured employee, including personal information, the date of injury, and specific employer and insurance carrier information. It enables the employee to track their healthcare coverage while ensuring that they are compliant with any medical examinations requested by their insurance provider. Additionally, the form addresses evaluations related to the Designated Doctor’s determination, a practice established to streamline the assessment of whether an injured party is at Maximum Medical Improvement or if their ability to return to work is accurately documented. Various sections on the DWC022 request confirmation of the appropriateness of healthcare received, ensuring that the necessary medical services align with the standards set forth by Texas Labor Code. Employees who receive medical benefits through a Certified Health Care Network or a political subdivision are advised of specific exceptions regarding the RME request. Overall, the DWC022 form is essential for maintaining clarity and communication between the employee, insurer, and healthcare providers throughout the claims process.

Texas Dwc022 Example

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

DWC022

Si desea hablar con alguien sobre este

Complete if known:

formulario o acerca de su reclamación,

 

llame al ajustador de su aseguradora al

DWC Claim #

número de teléfono que aparece en la

 

Casilla 15 de la Sección III.

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

16. Adjuster’s Fax Number

17. Adjuster’s License Number

 

(

)

ext.

(

)

 

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

Yes

No

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 Rev. 07/11

Page 1 of 3

 

 

 

 

 

DWC022

 

 

 

 

 

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

Yes

No

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 Rev. 07/11

Page 2 of 3

DWC022

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.

DWC022 Rev. 07/11

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Get Texas Dwc022 PDF Form

Form Characteristics

Fact Name Details
Purpose of the DWC022 Form The DWC022 form serves as a request for a Required Medical Examination (RME) related to workers' compensation claims in Texas. It can be used for evaluating a designated doctor's determination or assessing the appropriateness of healthcare received.
Governing Laws The use of the DWC022 form is governed by the Texas Labor Code, specifically sections §408.004 (Appropriateness of Health Care Examination) and §504.053, which pertains to medical benefits provided through political subdivisions.
Time Requirements An employee must respond to the request for an RME within 15 days of receipt. If the request is approved, the employee is mandated to attend the examination.
Travel Considerations If the examination location is over 75 miles from the employee's address, an explanation is required. The employee may also seek travel reimbursement by using the appropriate forms.
Frequency of Examination Examinations to determine the appropriateness of healthcare received cannot occur more than once every 180 days. However, evaluations concerning designated doctors can be scheduled more frequently, depending on the circumstances.

Guidelines on Utilizing Texas Dwc022

Filling out the Texas DWC022 form requires attention to detail and accuracy. This form is commonly used in workers' compensation cases to initiate a Required Medical Examination (RME). Completing it properly ensures that all necessary information is provided for the examination process. Here’s a step-by-step guide to help navigate through the form smoothly.

  1. Start with Section I: Employee/Employee’s Attorney Information. Provide the employee's full name, Social Security Number, address, and phone numbers. Also include the date of injury and the attorney's information if applicable.
  2. Move to Section II: Employer Information. Fill out the employer's name and address at the time of the injury.
  3. Proceed to Section III: Insurance Carrier Information. Complete the fields with the insurance carrier's name, address, and adjuster's contact information.
  4. In Section IV, provide details about the examining RME doctor including their name, mailing address, license number, and phone number. Don’t forget the examination location and date/time of appointment.
  5. Answer questions regarding whether the claim involves specific medical benefits or if the employee’s address and examination location are over 75 miles apart.
  6. In Section V, specify the purpose of the examination. Include the designated doctor’s name, date of examination, and check off relevant issues to be addressed.
  7. Section VI requires the insurance carrier’s certification. Sign and print your name, title, and date of signature.
  8. If you are addressing the appropriateness of health care received, complete Sections VII and VIII. Follow similar steps as above, filling in the doctor’s information and obtaining agreement from the injured employee where necessary.
  9. Finally, Section IX requires the injured employee’s agreement or non-agreement to attend the examination, including their signature and date.

With these steps completed, make sure all information is clear and legible before submitting the form. This attention to detail helps facilitate a smoother examination process and ensures that all parties are informed.

What You Should Know About This Form

What is the purpose of the Texas DWC022 form?

The Texas DWC022 form is used to request a Required Medical Examination (RME) by an insurance carrier. This examination may help determine two primary issues: the evaluation of a Designated Doctor determination or the appropriateness of health care received by the injured employee. If you’ve been examined by a Designated Doctor, the insurance carrier might request an RME to address the same issues discussed in that examination. Alternatively, if there's a need to evaluate the appropriateness of health care you received, the insurance carrier will seek your agreement to attend this examination.

Who fills out the Texas DWC022 form?

This form is typically completed by the insurance carrier or the adjuster representing the insurance company. The form must include detailed information about the employee, their employer, and the insurance provider. It will also require information regarding the doctor who will perform the examination and the purpose behind the request. It’s important for all information to be accurate and completed properly to avoid delays in processing.

How often can an RME be requested under this form?

An RME to assess the appropriateness of health care can be requested no more than once every 180 days. However, examinations that evaluate a Designated Doctor’s determination can take place more frequently. Additionally, once you’ve received Supplemental Income Benefits for eight quarters, an RME focused on your ability to return to work may also be requested no more than once per year.

What happens if I cannot attend the scheduled examination?

If you are unable to attend the RME, you should contact the doctor’s office to reschedule at least 24 hours in advance. The new appointment must occur no later than 7 days after the original date unless a different date is mutually agreed upon. Make sure you inform the office about your situation to avoid any repercussions, as missing a scheduled appointment may be viewed as an administrative violation.

Common mistakes

Filling out the Texas DWC022 form correctly is vital for ensuring a smooth claims process. Many people make mistakes that can lead to delays or complications. One common error is failing to include complete names for the employee and the insurance adjuster. Both the first and last names must be provided, as incomplete information can hinder communication and responsiveness.

Another frequent oversight involves neglecting to enter the correct social security number for the employee. A missing or incorrect number can cause significant delays in processing the request, since it is critical for identifying the claim. Additionally, many forget to include the telephone numbers needed for urgent communication. Having alternate contact numbers listed can make a huge difference when quick updates or confirmations are necessary.

In the section regarding examination details, inaccuracies regarding the date and time of the appointment are often made. This can lead to misunderstandings between the injured employee and the medical provider. It is essential to double-check that all dates are clearly written and free from errors. Furthermore, some individuals overlook the necessity of providing valid reasons when the examination location exceeds 75 miles from the employee's address. A lack of explanation can create confusion and unnecessary rejection of the request.

Misunderstanding the purpose of the examination is another mistake. Applicants frequently check boxes without fully comprehending what they signify. For example, not clarifying if the medical benefits involve a certified health care network can result in a denied request. It is crucial to understand and correctly answer inquiries regarding the specifics of the claim.

Completing the certification section improperly is also a common issue. Individuals often forget to sign the form or miss entering the date of their signature. Such omissions can render the submission invalid. Moreover, many do not retain copies of submitted forms for their records. Keeping a copy ensures that both the employee and the insurance carrier are on the same page during future communications.

Finally, miscommunication following the submission is a typical pitfall. Some neglect to follow up after sending the form. Checking for confirmation that the submission has been received can prevent miscommunication later on. By being aware of these potential mistakes and taking steps to avoid them, individuals can streamline the process and improve their claim outcomes.

Documents used along the form

The Texas DWC022 form serves as a critical document in the workers' compensation process, specifically relating to Required Medical Examinations (RMEs). While this form addresses various requests for examinations involving the injured employee, it is often accompanied by several other forms and documents. Understanding these related forms is essential for anyone navigating the claims process in Texas.

  • DWC Form-069: Also known as the "Report of Medical Evaluation," this document is completed by the Designated Doctor after the examination. It includes the findings related to the employee's condition and whether they have reached Maximum Medical Improvement.
  • DWC Form-048: This is the "Request for Travel Reimbursement" form. Injured employees can use it to request reimbursement for travel expenses incurred when attending an RME. Proper documentation should accompany the request to ensure expenses are justified.
  • DWC Form-073: This form pertains to the "Ability to Return to Work." It assesses the employee's capacity to return to their job after an injury and may be a consideration in various evaluations.
  • DWC Form-030: Known as the "Employee's Notice of Injury," this document is used by employees to notify their employer of a work-related injury. It sets the stage for the workers' compensation claim process and is often referenced during medical evaluations.
  • DWC Form-002: This form serves as the "Employee’s Claim for Compensation." It formally begins the claims process and outlines the details of the employee’s injury, including medical treatment received and the impact on their ability to work.

In summary, these forms work together with the DWC022 to facilitate a comprehensive review and assessment of medical inquiries related to workers' compensation claims. Familiarity with these documents can significantly aid injured employees in understanding their rights and navigating the complexities of the claims process.

Similar forms

  • Texas DWC Form-073: Similar to the DWC022, this form is used for assessing the employee’s ability to return to work. Both documents evaluate critical aspects related to medical examinations but focus on different elements within the workers' compensation process.
  • Texas DWC Form-048: This form requests travel reimbursement for attending a Required Medical Examination. Much like the DWC022, it ensures support for injured employees participating in examinations, emphasizing the importance of their engagement in the claims process.
  • Texas DWC Form-041: This document is used for requesting a benefit review conference. Both forms play significant roles in the claims process and document necessary communications regarding an employee's injury and benefits entitlement.
  • Texas DWC Form-005: This form serves as a notice of injury. Similar to DWC022, it is foundational in the workers' compensation framework, ensuring that pertinent information about the injury and subsequent examinations is clearly documented and accessible.

Dos and Don'ts

Do's:

  • Ensure all personal information is accurate and up to date.
  • Double-check the dates, especially the Date of Injury.
  • Include all required signatures and certifications.
  • Clearly mark any special circumstances, such as travel requirements exceeding 75 miles.
  • Use clear and concise language throughout the form.
  • Attach any necessary documentation to support your request.
  • Keep a copy of the completed form for your records.

Don'ts:

  • Do not leave any sections blank unless instructed otherwise.
  • Avoid vague explanations; be specific in your responses.
  • Do not submit the form without verifying the accuracy of all details.
  • Do not rush through the process; take your time to fill it out properly.
  • Do not forget to follow up if you do not receive confirmation of your submission.
  • Avoid using legal jargon; keep it simple and straightforward.
  • Do not ignore deadlines for submission; submit promptly.

Misconceptions

Misconceptions about the Texas DWC022 form can lead to confusion regarding the workers' compensation process. Below are ten common misconceptions along with explanations to clarify them.

  1. It is only necessary for certain employees. Any injured employee may be required to complete this form, regardless of their employer or the nature of their injuries.
  2. The form is optional. Completing the DWC022 is often mandatory when a Required Medical Examination (RME) is requested by the insurance carrier.
  3. All RMEs are the same. There are different types of RMEs, such as those evaluating a designated doctor's determination and those assessing the appropriateness of health care received.
  4. The insurance carrier can force an employee to attend the RME. Employees must agree to attend, but if they refuse, the carrier can seek an order from TDI-DWC to compel attendance.
  5. The employee must go to any doctor the insurance carrier selects. While the insurance carrier chooses the doctor, the employee can request that their treating doctor also attends the RME.
  6. The form must be returned immediately. Employees have 15 days to complete Section IX of the form and return it to the insurance carrier.
  7. A failure to attend the RME has no consequences. Not attending a scheduled RME may be seen as an administrative violation, potentially affecting benefits.
  8. The distance for an RME does not matter. If the employee's address and the examination location are over 75 miles apart, an explanation must be provided.
  9. Travel expenses for the RME will always be reimbursed. To receive travel reimbursement, a separate DWC-Form 048 must be completed, following specific guidelines.
  10. Completing the form guarantees a favorable outcome. The completion of the DWC022 does not influence the outcome of the workers' compensation claim; it is simply a part of the process.

Understanding these misconceptions will help injured employees navigate the Texas workers' compensation system more effectively.

Key takeaways

  • The Texas DWC022 form is crucial for both employees and insurance carriers when it comes to Required Medical Examinations (RME).
  • Filling out the form is a multi-step process, with Sections dedicated to employee information, employer details, and insurance carrier specifics.
  • In the event of a disagreement regarding the examination, the employee has a 15-day window to respond to the request.
  • If the employee declines to attend the RME, the insurance carrier may still seek an order from the Texas Department of Insurance - Division of Workers' Compensation (TDI-DWC).
  • RMEs are allowed only once every 180 days to evaluate the appropriateness of health care received, with more frequent evaluations permitted for other assessments.
  • It is necessary for the selected RME doctor to not have any disqualifying associations with the employee or the insurance carrier, ensuring an unbiased examination.
  • Travel reimbursements for attending RMEs can be requested using a separate form, emphasizing the importance of understanding rights and available resources.

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