The Texas DWC022 form is a document used in the Texas workers' compensation system, specifically for requesting a Required Medical Examination (RME). This form facilitates communication between injured employees, their employers, and insurance carriers regarding medical evaluations necessary for claims processing. Understanding how to accurately fill out this form is crucial for ensuring that all parties are aligned and that the injured employee receives the appropriate care and assessments.
If you need to fill out the Texas DWC022 form, click the button below.
When filling out the Texas DWC022 form, there are important dos and don'ts to keep in mind. Following these guidelines can help ensure a smooth process.
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.
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
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?
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
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.
VIII. INSURANCE CARRIER CERTIFICATION
47.I hereby certify the following:
•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)
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
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).
Page 2 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.
Page 3 of 3
Medicaid Forms Online - The form allows for systematic planning of caregiver tasks and responsibilities.
Petition to Modify the Parent-child Relationship - Form clarity and thoroughness are essential to minimize procedural complications during modification hearings.
The Texas DWC022 form is an essential document used in the workers' compensation process for requesting a Required Medical Examination (RME). Several other forms and documents often accompany it to ensure a smooth and comprehensive handling of claims. Below is a list of these related documents.
These forms work together to facilitate the workers' compensation process in Texas. Ensuring that all necessary documents are completed and submitted accurately can help avoid delays and complications in claims processing.
Completing the Texas DWC022 form can be a straightforward process, but several common mistakes can lead to complications. One frequent error is failing to provide complete information in the Employee Information section. Missing details such as the employee's name, Social Security number, or address can delay the processing of the request. Ensuring that all fields are filled out accurately is essential for timely communication with the insurance carrier.
Another mistake often made involves the Date of Injury. Entering the incorrect date can lead to confusion regarding the claim timeline. It is crucial to verify that the date matches the actual date of the injury. This error can complicate the relationship between the employee and the insurance carrier, potentially affecting the outcome of the claim.
In the Insurance Carrier Information section, individuals may overlook the necessity of including the adjuster’s contact details. Failing to provide the adjuster’s name, email, or telephone number can hinder communication. This information is vital for the insurance carrier to process the request efficiently and respond to any inquiries.
Additionally, individuals sometimes neglect to check the relevant boxes in the Purpose of Examination section. Each box should be reviewed carefully to ensure that the correct issues are addressed. Not checking the appropriate boxes may lead to misunderstandings about the purpose of the examination, which could affect the outcome.
Errors in the Insurance Carrier Certification section can also occur. For instance, failing to sign the form or not providing the printed name and title of the adjuster can render the form incomplete. This certification is a critical component of the form, as it confirms that the request is accurate and that the insurance carrier is authorized to act on behalf of the employee.
Lastly, individuals may forget to complete the Injured Employee Agreement/Non-Agreement section. This section is crucial for indicating whether the employee agrees to attend the examination. If this section is left blank or filled out incorrectly, it may lead to complications regarding the scheduling of the examination and the overall claims process. Ensuring that all sections are completed thoroughly is essential for a smooth experience with the Texas DWC022 form.
Misconceptions about the Texas DWC022 form can lead to confusion for injured employees and insurance carriers alike. Here are nine common misunderstandings:
Understanding these misconceptions can help navigate the complexities of the workers' compensation system in Texas more effectively.
The Texas DWC022 form is essential for requesting a Required Medical Examination (RME) related to workers' compensation claims. It facilitates communication between the insurance carrier and the injured employee.
Accurate completion of the form is crucial. Each section must be filled out with precise information, including employee details, employer information, and insurance carrier specifics.
Employees have 15 days to respond to the request for an RME. They must complete the agreement/non-agreement section and return the form to the insurance carrier within this timeframe.
If an employee disagrees with attending the RME, the insurance carrier may seek an order from TDI-DWC to compel attendance. This could lead to administrative penalties if the employee fails to comply with a subsequent order.
Examinations to assess the appropriateness of health care received can only occur once every 180 days. However, evaluations of designated doctor determinations can happen more frequently.
Travel reimbursement may be available for employees attending an RME. To request this, they must complete the DWC-Form 048, ensuring they keep records of their travel expenses.
In cases involving certified health care networks or certain political subdivisions, the insurance carrier may have limitations on requesting an RME. Employees should be aware of these exceptions.
Filling out the Texas DWC022 form is an important step in the process of requesting a Required Medical Examination (RME). This form collects necessary information about the employee, employer, insurance carrier, and the examination itself. It is crucial to provide accurate and complete information to avoid any delays in processing.
After completing the form, it is important to keep a copy for your records. Submit the completed form to the appropriate parties as required. If there are any questions or if further assistance is needed, contacting the Texas Department of Insurance Division of Workers’ Compensation is recommended.