The Texas DWC069 form, known as the Report of Medical Evaluation, is a critical document used in the workers' compensation process. This form is completed by medical professionals to report on an injured employee's maximum medical improvement (MMI) and any permanent impairment resulting from a workplace injury. Accurate completion of this form is essential for both the employee's ongoing medical benefits and the resolution of their claim.
To ensure proper processing, fill out the Texas DWC069 form by clicking the button below.
When filling out the Texas DWC069 form, there are several important practices to keep in mind to ensure accuracy and compliance. Here’s a list of things you should and shouldn’t do:
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
Page 1 of 3
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.
Page 2 of 3
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).
Page 3 of 3
Texas Dps License to Carry - Legal consequences exist for omitting or misstating information on the application.
What Is My Medicaid Number - A signature and date are required on Page 6 of the form.
Dl 44 Form Dmv - Each section of the form must be filled out completely.
The Texas DWC069 form, known as the Report of Medical Evaluation, is an essential document in the Texas workers' compensation system. It is used by medical professionals to certify an injured employee's maximum medical improvement (MMI) and any permanent impairment resulting from a workplace injury. Several other forms and documents are commonly used in conjunction with the DWC069 to ensure a comprehensive evaluation and processing of workers' compensation claims. Below is a list of these documents.
Each of these documents plays a crucial role in the workers' compensation process in Texas. Proper completion and submission of these forms help ensure that claims are processed efficiently and that injured employees receive the benefits they are entitled to. Understanding the purpose of each document can aid both employees and medical professionals in navigating the complexities of the system.
Filling out the Texas DWC069 form can be a challenging process, and mistakes can lead to delays or complications in workers' compensation claims. One common error is failing to provide complete and accurate general information. This includes essential details such as the injured employee's name, date of injury, and social security number. Omitting any of these details can result in the form being returned or delayed, which can hinder the employee's access to necessary benefits.
Another frequent mistake involves the certification of Maximum Medical Improvement (MMI). Many individuals incorrectly mark prospective dates for MMI, which is not allowed. The form explicitly states that the MMI date cannot be a future date. Additionally, failing to include the required documentation that supports the MMI certification can lead to further complications. Proper documentation is crucial for validating the certification and ensuring that the claim is processed smoothly.
Errors can also occur in the section regarding permanent impairment. Some doctors may mistakenly certify that an employee has no permanent impairment when, in fact, they do. This misrepresentation can have serious consequences, as it may deny the employee the benefits they are entitled to. It is essential that the impairment rating is based on objective clinical findings and that the appropriate documentation is included to support this assessment.
Inaccuracies in the doctor's information section are another area where mistakes frequently happen. Providing incorrect license numbers or failing to include the doctor’s contact information can cause delays in communication between the involved parties. This can lead to misunderstandings or mismanagement of the claim, which may affect the injured employee’s access to care and benefits.
Finally, many individuals overlook the importance of the doctor's certification at the end of the form. The certifying doctor must ensure that they have completed all required training and have the necessary certifications to assign impairment ratings. Failing to verify these qualifications can invalidate the report and lead to legal repercussions. Therefore, it is critical for doctors to double-check their credentials and ensure compliance with all relevant regulations before submitting the form.
Understanding the Texas DWC069 form can be challenging, and several misconceptions often arise. Here are eight common misunderstandings, along with clarifications to help you navigate this important document.
While treating doctors often file this form, other authorized doctors, such as designated doctors or those selected by the treating doctor, can also submit it.
This form is primarily used to report MMI, but it can also be filed for employees who have not yet reached MMI, especially if a dispute arises.
Certification of MMI does not terminate an employee's right to medical benefits. Employees can still receive necessary medical care even after reaching MMI.
Only doctors certified by the Texas Department of Insurance to assign impairment ratings can do so. Others may only determine if there is permanent impairment.
The form must be filed no later than the seventh working day after the examination or after receiving all necessary medical information.
This form can be submitted via facsimile or electronic transmission, which may speed up the process.
A finding of no impairment is not the same as a 0% impairment rating. A doctor must conduct an examination to assign any impairment rating.
Employees have the right to dispute the certification of MMI and the assigned impairment rating within 90 days of receiving notice.
By addressing these misconceptions, individuals can better understand the DWC069 form and its implications within the Texas workers' compensation system.
The Texas DWC069 form is used to report medical evaluations related to workers' compensation claims.
Complete the form accurately, including all required information such as the employee's name, date of injury, and social security number.
Only authorized doctors can fill out and submit the DWC069. This includes treating doctors, designated doctors, and specific doctors selected by the treating doctor.
It is crucial to indicate whether the employee has reached Maximum Medical Improvement (MMI) and to provide supporting documentation.
If the employee has reached MMI, the form must also address any permanent impairment resulting from the injury.
The DWC069 must be filed within seven working days after the examination or receipt of necessary medical information.
Submit the completed form to multiple parties, including the insurance carrier, treating doctor, and the Texas Department of Insurance.
Maintain documentation of the examination and report, including dates and means of communication.
If there is disagreement regarding the MMI certification or impairment rating, the injured employee has the right to dispute the findings within 90 days.
Completing the Texas DWC069 form involves several steps to ensure accurate reporting of medical evaluations related to workers' compensation claims. This process requires careful attention to detail, as the information provided will impact the claim's outcome.
Once the form is completed and submitted, it will be processed by the relevant parties. Ensure that all documentation is maintained for your records, as this may be needed for future reference or disputes.