The Texas DWC069 form, officially known as the Report of Medical Evaluation, is a critical document used within the Texas workers' compensation system. It is designed to record the findings of a medical evaluation concerning an injured employee, indicating whether the employee has reached Maximum Medical Improvement (MMI) and if there's any permanent impairment as a result of the work-related injury. Filling out this form accurately is crucial for ensuring that injured workers receive the appropriate benefits. To get started with this form, click the button below.
The Texas Department of Insurance Division of Workers’ Compensation introduces a critical document, the DWC069 form, which plays a pivotal role in the workers' compensation process. This form is essential for reporting medical evaluations concerning an employee’s Maximum Medical Improvement (MMI) and assessing any permanent impairment resulting from a workplace injury. As such, it requires input from various stakeholders, including the treating doctor, designated doctor selected by the DWC, or an insurance carrier-selected Required Medical Examination (RME) doctor, each with specific authorizations under the 28 Texas Administrative Code §130.1. The DWC069 form encompasses several key sections: General Information of the involved parties, the Doctor’s Role in the evaluation, the Medical Status Information indicating the employee’s MMI status, and the crucial segment on Permanent Impairment, which determines the extent of any lasting physical damage post-recovery. Additionally, it outlines the procedural steps for certifying doctors, including detailed instructions on filing, document maintenance, and compliance with the Texas Labor Code, ensuring the integrity and accuracy of the evaluation process. This form not only serves as a comprehensive tool for evaluating an injured employee's medical condition but also as a procedural guide for doctors, ensuring all evaluations adhere to regulatory standards and requirements.
Texas Department of Insurance
Division of Workers’ Compensation
7551 Metro Center Drive, Suite 100 MS-94 Austin, TX 78744-1645
(800) 252-7031 phone (512) 490-1047 fax
Report of Medical Evaluation
DWC069
Complete if known:
DWC Claim #
Carrier Claim #
I. GENERAL INFORMATION
4. Injured Employee's Name (First, Middle, Last)
1.
Workers’ Compensation Insurance Carrier
5.
Date of Injury
6. Social Security Number
2.
Employer’s Name
7. Employee's Phone Number
3.
Employer’s Address (Street or PO Box, City State Zip)
8.
Employee’s Address (Street or PO Box, City State Zip)
9.Certifying Doctor's Name and License Type
10.Certifying Doctor's License Number and Jurisdiction
11.Certifying Doctor’s Phone and Fax Numbers
(Ph)(Fax)
12.Certifying Doctor’s Address (Street or PO Box, City State Zip)
II. DOCTOR’S ROLE
13.Indicate which role you are serving in the claim in performing this evaluation. Only a doctor serving in one of the following roles is authorized to evaluate MMI/impairment and file this report [28 Texas Administrative Code (TAC) §130.1 governs such authorization]:
Treating Doctor
Doctor selected by Treating Doctor acting in place of the Treating Doctor
Designated Doctor selected by DWC
Insurance Carrier-selected RME Doctor approved by DWC to evaluate MMI and/or permanent impairment after a Designated Doctor examination NOTE: If you are not authorized by 28 TAC §130.1 to file this report, you will not be paid for this report or the MMI/impairment examination.
III. MEDICAL STATUS INFORMATION
14. Date of Exam
15. Diagnosis Codes
____ / ____ / ________
16. Indicate whether the
employee has reached Clinical or Statutory MMI based upon the following definitions:
Clinical Maximum Medical Improvement (Clinical MMI) is the earliest date after which, based upon reasonable medical probability, further material recovery from or lasting improvement to an injury can no longer reasonably be anticipated.
Statutory MMI is the later of: (1) the end of the 104th week after the date that temporary income benefits (TIBs) began to accrue; or
(2)the date to which MMI was extended by DWC pursuant to Texas Labor Code §408.104.
a) Yes, I certify that the employee reached STATUTORY / CLINICAL (mark one) MMI on ____ / ____ / ________
(may not be a prospective date) and have included documentation relating to this certification in the attached narrative. - OR -
b) No, I certify that the employee has NOT reached MMI but is expected to reach MMI on or about ____ / ____ / ________
The reason the employee has not reached MMI is documented in the attached narrative.
NOTE: The fact that an employee reaches either Clinical MMI or Statutory MMI does not signify that the employee is no longer entitled to medical benefits.
IV. PERMANENT IMPAIRMENT
17. If the employee has reached MMI, indicate whether the employee has permanent impairment as a result of the compensable injury.
“Impairment” means any anatomic or functional abnormality or loss existing after MMI that results from a compensable injury and is reasonably presumed to be permanent. The finding that impairment exists must be made based upon objective clinical or laboratory findings meaning a medical finding of impairment resulting from a compensable injury, based upon competent objective medical evidence that is independently confirmable by a doctor, including a designated doctor, without reliance on the subjective symptoms perceived by the employee.
a) I certify that the employee does not have any permanent impairment as a result of the compensable injury. - OR -
b) I certify that the employee has permanent impairment as a result of the compensable injury. The amount of permanent impairment is _____%, which was determined in accordance with the requirements of the Texas Labor Code and Texas Administrative Code. The attached narrative provides explanation and documentation used for the calculation of the impairment rating assigned using the appropriate tables, figures, or worksheets from the following
edition of the Guides to the Evaluation of Permanent Impairment published by the American Medical Association (AMA): third edition, second printing, February 1989 - OR -
fourth edition, 1st, 2nd, 3rd, or 4th printing, including corrections and changes issued by the AMA prior to May 16, 2000.
NOTE: A finding of no impairment is not equivalent to a 0% impairment rating. A doctor can only assign an impairment rating, including a 0% rating, if the doctor performed the examination and testing required by the AMA Guides.
V. DOCTOR’S CERTIFICATION
18.I HEREBY CERTIFY THAT THIS REPORT OF MEDICAL EVALUATION is complete and accurate and complies with the Texas Labor Code and applicable rules. If an impairment rating has been assigned, I certify that I have completed the required training and testing and have a current certification by DWC to assign impairment ratings in the Texas workers' compensation system or have received specific permission by DWC to certify MMI and assign an impairment rating. I understand that making a misrepresentation about a workers’ compensation claim or myself is a crime that can result in fines and/or imprisonment and nullification of this report.
Signature of Certifying Doctor: _________________________________________________
Date of Certification: __________________
VI. TREATING DOCTOR’S AGREEMENT OR DISAGREEMENT WITH ANOTHER DOCTOR’S CERTIFICATION
19.
Treating Doctor's Name and License Type
22.
I AGREE / I DISAGREE with the certifying doctor’s certification of MMI.
20.
Treating Doctor's License Number and Jurisdiction
23.
I AGREE / I DISAGREE with the certifying doctor’s finding of no impairment. - OR -
21.
Treating Doctor’s Phone and Fax Numbers
I AGREE / I DISAGREE with the impairment rating assigned by the certifying doctor.
(Ph)
(Fax)
24.I understand that making a misrepresentation about a workers’ compensation claim is a crime that can result in fines and/or imprisonment.
Signature of Treating Doctor: __________________________________________________
Date: _____________________________
DWC069 Rev. 01/15
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Frequently Asked Questions
Report of Medical Evaluation (DWC Form-069)
INSTRUCTIONS FOR DOCTORS:
Who can file the DWC Form-069?
Treating Doctor: Doctor chosen by the employee who is primarily responsible for employee's injury-related health care.
Doctor Selected by Treating Doctor: Doctor selected by the treating doctor to evaluate permanent impairment and Maximum Medical Improvement (MMI). This doctor acts in the place of the treating doctor. Such a doctor must be selected if the treating doctor is not authorized to certify MMI or assign an impairment rating in those cases in which the employee has permanent impairment. An authorized treating doctor may also choose to select another doctor to perform the evaluation/certification.
Designated Doctor: Doctor selected by the Texas Department of Insurance, Division of Workers’ Compensation (DWC) to resolve a question over MMI or permanent impairment.
Insurance Carrier-Selected RME Doctor: Doctor selected by the insurance carrier to evaluate MMI and/or permanent impairment. An insurance carrier-selected Required Medical Examination (RME) Doctor is only authorized to certify MMI, evaluate permanent impairment, and assign an impairment rating when specifically approved by DWC prior to the examination and only after a designated doctor has completed the same.
AUTHORIZATION: In addition to the requirement of acting in an eligible role, 28 Texas Administrative Code §130.1 provides the following requirements:
Employee has permanent impairment: Only a doctor certified by DWC to assign impairment ratings or who receives specific
permission by exception granted by DWC is authorized to certify MMI and to assign an impairment rating.
Employee does not have permanent impairment: A doctor not certified or exempted from certification by DWC is only authorized to determine whether an employee has permanent impairment and, in the event that the employee has no impairment, certify MMI.
INVALID CERTIFICATION: Certification by a doctor who is not authorized is invalid.
Under what circumstances and when am I required to file the DWC Form-069?
If the employee has reached MMI, you must file the DWC Form-069 no later than the seventh working day after the later of: (a) date of the certifying examination; or (b) receipt of all medical information necessary to certify MMI. Only a Designated Doctor is subject to this requirement if the employee has not reached MMI.
Where do I file the form?
The DWC Form-069 and required narrative shall be filed with:
the insurance carrier;
the treating doctor (if a doctor other than the treating doctor files the report);
DWC;
injured employee; and
injured employee’s representative (if any).
The report must be filed by facsimile or electronic transmission unless an exception applies. The specific requirements are shown below. To file this form with DWC, fax to (512) 490-1047.
Insurance Carrier
DWC
Designated Doctor
fax or e-mail
fax or e-mail unless recipient has
Doctor Selected by Treating Doctor
not provided these numbers; then
Insurance Carrier-Selected RME Doctor
by other verifiable means
Injured Employee
Injured Employee’s Representative
fax or e-mail unless recipient has not provided these numbers; then by other verifiable means
Do I have to maintain documentation regarding the examination and report?
The certifying doctor must maintain the original copy of the report and narrative and documentation of the following:
date of the examination;
date any medical records necessary to make the certification of MMI were received, and from whom the medical records were received; and
date, addresses, and means of delivery that required reports were transmitted or mailed by the certifying doctor.
Where can I find more information about the Report of Medical Evaluation?
See 28 TAC §130.1 through §130.4 and §130.6 for the complete requirements regarding the filing of this report, including required documentation. The complete text of these rules is available on the Texas Department of Insurance website at www.tdi.texas.gov/wc/rules/index.html. If you have additional questions, call 1-800-372-7713, Option #3.
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IMPORTANT INFORMATION FOR INJURED EMPLOYEES:
What if I disagree with the doctor's certification of Maximum Medical Improvement (MMI) and/or permanent impairment rating for my workers' compensation claim?
If this is the first evaluation of your MMI and/or permanent impairment, you or your representative may dispute:
the certification of MMI; and/or
the assigned impairment rating.
To file the dispute, contact your local DWC field office or call 1-800-252-7031 to request:
the appointment of a designated doctor (DD), if one has not been appointed; or
a Benefit Review Conference (BRC).
Important Note: Your dispute must be filed within 90 days after the written notice is delivered to you or the certification of MMI and/or the assigned impairment rating may become final.
NOTE: With few exceptions, upon your request, you are entitled to be informed about the information DWC collects about you; receive and review the information (Government Code, §§552.021 and 552.023); and have DWC correct information that is incorrect (Government Code, §559.004).
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After receiving the Texas DWC069 form, it's crucial to complete it with precision and detail. This document is essential for reporting a medical evaluation regarding a workers' compensation claim. The steps provided below aim to guide you smoothly through the process, ensuring that all necessary information is accurately reported. Remember, this form plays a significant role in the claim process, affecting the injured employee's benefits and further medical management.
After filling out the form accurately, it must be submitted according to the instructions provided, which includes sending copies to the insurance carrier, treating doctor, DWC, injured employee, and potentially the employee's representative. The filing process is usually done through fax or email, unless an exception applies. This step is critical for ensuring the form is processed efficiently and reaches all involved parties. Compliance with the submission guidelines supports a smooth continuation of the compensation claim process.
Filing the Report of Medical Evaluation (DWC Form-069) can be done by various medical professionals within certain guidelines. The eligible parties include the treating doctor, who is the primary healthcare provider for the injury-related healthcare of the employee. Alternatively, a doctor selected by the treating doctor can evaluate permanent impairment and Maximum Medical Improvement (MMI) if the treating doctor is not authorized to certify MMI or assign an impairment rating. Designated doctors selected by the Texas Department of Insurance, Division of Workers’ Compensation (DWC), and insurance carrier-selected Required Medical Examination (RME) Doctors, specifically approved by DWC, can also file this form following a designated doctor’s examination.
The DWC Form-069 needs to be filed under specific conditions. If the employee has reached MMI, the form must be submitted no later than seven working days after the date of the certifying examination or, if later, after receiving all medical information necessary to certify MMI. This requirement is explicitly applicable only to designated doctors if the employee has not yet reached MMI.
The DWC Form-069, along with the required narrative, should be concurrently filed with several parties to ensure proper documentation and communication. These include the insurance carrier, the treating doctor (if another doctor is filing the report), DWC, the injured employee, and the employee’s representative, if they have one. Submission is generally preferred through facsimile or electronic transmission, except under certain circumstances where other verifiable means are permitted.
Yes, the doctor certifying the DWC Form-069 is required to retain the original copy of the report and narrative. Additionally, they must document the date of the examination, when any necessary medical records were received and from whom, and the details of how and when the required reports were sent to the involved parties.
For comprehensive details on the requirements and guidelines surrounding the filing of DWC Form-069, individuals are encouraged to review sections 28 TAC §130.1 through §130.4 and §130.6. These sections cover all necessary documentation and procedural steps. The complete text of these rules is available on the Texas Department of Insurance website. For further queries, individuals can call the provided helpline number.
If an injured employee disagrees with the certification of MMI or the assigned impairment rating, they have the right to dispute the evaluation. This is particularly pertinent if it is the first evaluation received. The employee or their representative can seek the appointment of a designated doctor if one has not been appointed already or request a Benefit Review Conference (BRC). It is crucial to note that disputes must be filed within 90 days after the written notice has been delivered, or the certification and impairment rating may become final.
When individuals fill out the Texas DWC069 form, which serves as a Report of Medical Evaluation for workers' compensation claims, inaccuracies or misunderstandings can lead to mistakes. Here are ten common errors that can occur during the completion of this form:
Providing incomplete or incorrect general information, such as the injured employee's name, worker’s compensation insurance carrier, or employer's name and address. This crucial first step requires attention to detail to ensure the accuracy of the submitted report.
Entering an incorrect or missing DWC Claim # or Carrier Claim #. These numbers are vital for tracking and linking the report to the specific claim within the Texas Department of Insurance Division of Workers' Compensation system.
Failure to specify the doctor's role in the claim accurately. This includes whether the doctor is the treating doctor, a doctor acting in place of the treating doctor, a designated doctor selected by DWC, or an insurance carrier-selected RME doctor. Correct identification of the role is critical for the authorization process.
Diagnosis Codes are not precisely entered. Using the accurate and specific diagnosis codes helps to ensure that the medical evaluation is correctly categorized and processed.
Omitting the Date of Exam or entering a future date instead of the date the examination actually took place, which goes against the requirement that the date cannot be prospective.
Incorrectly indicating whether the employee has reached Clinical or Statutory Maximum Medical Improvement (MMI). Understanding the distinction between the two and providing documentation for the certification is imperative.
Failure to accurately determine if the employee has permanent impairment and, if so, incorrectly calculating the impairment rating percentage. This section requires detailed medical assessment and adherence to the AMA Guides specified by Texas law.
Incorrectly completing the doctor's certification section, either by not certifying that the report complies with the Texas Labor Code and applicable rules or by failing to recognize the importance of having the required training and certification to assign impairment ratings.
Not properly addressing the treating doctor’s agreement or disagreement with another doctor’s certification. This part of the form is essential for cross-verifying the medical evaluation and ensuring consensus or noting disputes within the medical assessments provided.
Failing to meet the filing requirements, which include submitting the form to the insurance carrier, treating doctor (if different from the doctor filing the report), DWC, injured employee, and injured employee’s representative if applicable, via the specified methods (fax or electronic transmission, unless an exception applies).
These mistakes can delay the processing of a worker's compensation claim or lead to disputes that may require resolution through additional administrative steps. It's important for all parties involved in filling out the Texas DWC069 form to carefully review the form's instructions and requirements to ensure accurate and complete submissions.
When dealing with workers' compensation claims in Texas, the DWC069 Report of Medical Evaluation form is pivotal. However, it doesn't stand alone. To navigate these claims effectively, a bouquet of additional forms and documents often come into play, creating a comprehensive framework for managing and resolving workers' compensation cases. Let's explore some of these critical documents that usually accompany the DWC069 form, each serving a unique but interconnected role in the broader workers' compensation landscape.
The labyrinthine nature of workers' compensation claims demands not only a keen understanding of each form and its purpose but also an eye for detail and procedural accuracy. These documents work in concert to ensure that injured employees receive the medical care and financial support they need, while also safeguarding employers' and insurers' interests. Keeping these forms in your arsenal and understanding their interplay is key to navigating the complex terrain of workers' compensation claims in Texas.
The Texas DWC-069 form is notably similar to the California Workers' Compensation Form PR-2, which is a Progress Report by the treating physician. Both documents are crucial in the workers' compensation process, as they provide updates on the injured employee's medical status, including Maximum Medical Improvement (MMI) and any permanent impairment. These forms play a pivotal role in determining the continuation or modification of benefits, ensuring that the process is guided by clear medical evidence.
Another document resembling the Texas DWC-069 is the OSHA 300 Log, which records workplace injuries and illnesses. Though the OSHA 300 Log is fundamentally a record-keeping mechanism focusing on documenting workplace incidents, it shares the objective of the DWC-069 form in promoting a safe and healthy work environment. Both documents contribute to identifying patterns of injuries and the effectiveness of workplace safety measures.
The FMLA Certification of Health Care Provider form also shares commonalities with the Texas DWC-069. While the FMLA form is used to certify the need for family and medical leave due to serious health conditions, it parallels the DWC-069 in requiring detailed medical information to substantiate eligibility for benefits. Each document serves to validate health-related claims through professional medical assessment.
The Texas DWC-073 form, which is a Work Status Report, closely parallels the DWC-069 form in its functionality within workers' compensation. The DWC-073 form provides updates on an injured worker's ability to return to work, much like the DWC-069 reports on MMI and impairment. Both forms are critical in managing an employee's recovery process and work capabilities post-injury.
The Permanent Partial Disability (PPD) award letter, common in many workers' compensation systems, too resembles the DWC-069 form in its focus on assessing and quantifying permanent impairment. While the DWC-069 outlines the doctor's evaluation of permanent impairment, the PPD award letter translates this assessment into monetary compensation, demonstrating how medical evaluations directly impact financial outcomes for injured workers.
The Medical Treatment Guidelines, often used in workers' compensation, share a goal with the DWC-069 form: to ensure that medical treatment for work-related injuries is appropriate and effective. While the Medical Treatment Guidelines offer a blueprint for care, the DWC-069 contributes the treating physician's professional judgment on the patient's progress, highlighting the symbiosis between standardized care protocols and individualized medical evaluations.
The Return-to-Work (RTW) programs and documents, which outline a plan for reintegrating injured employees back into the workforce, correlate with the DWC-069's focus on MMI and impairment assessment. Both are integral to navigating the transition from injury to active employment, emphasizing the role of accurate medical evaluation in facilitating suitable work accommodations and duties.
The Benefit Review Conference (BRC) documents utilized within the Texas Workers' Compensation system for dispute resolution also tie closely with the DWC-069 form. The BRC process often relies on documents like the DWC-069 to understand the medical basis of disputes over MMI or impairment ratings, underscoring the form’s significance in arbitrating disagreements between parties within the workers' compensation context.
The Independent Medical Examination (IME) report is another document that echoes the DWC-069 in its objective to provide an unbiased medical evaluation related to a workers' compensation claim. Although conducted by a third-party physician, the IME report, like the DWC-069, is pivotal in assessing an injured worker’s medical status, impairment, and eligibility for benefits.
Lastly, Payne and Relief Forms, used in some jurisdictions for workers’ compensation cases, also share similarities with the Texas DWC-069. These forms document medical evaluations and treatments provided to injured workers, directly influencing decisions on the provision and duration of workers' compensation benefits. Like the DWC-069, they serve as critical evidence in managing and resolving workers' compensation claims.
When completing the Texas DWC069 form, accuracy and thoroughness are paramount. This document is crucial in the workers' compensation process, impacting the rights and benefits of injured employees. Below are seven essential dos and don'ts to guide you through the process of filling out this form.
By following these guidelines, medical professionals play a crucial role in the Texas workers' compensation system, contributing to its efficacy and fairness. Accurate and timely completion of the DWC069 form supports injured employees in receiving the benefits they are entitled to, ensuring that their recovery and return to work are managed effectively.
Understanding the DWC069 form used in Texas for workers' compensation cases is critical, yet many misconceptions exist about its purpose and use. This form, essential for reporting medical evaluations, often surfaces misunderstandings that can complicate workers' compensation claims. Let's explore seven common misconceptions:
Clearing up these misconceptions is vital for accurately navigating the processes of medical evaluation and impairment assessment in Texas workers' compensation cases. Understanding the specific requirements, authorized participants, and implications of the DWC069 form ensures more straightforward, transparent handling of workers’ compensation claims for all parties involved.
Understanding the Texas DWC069 form is crucial for anyone involved in the Workers' Compensation process. Here are key takeaways to assist in filling out and using this form:
Thoroughly understanding and correctly utilizing the Texas DWC069 form ensures that Workers' Compensation claims are processed accurately and efficiently, benefiting all parties involved.
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