The Texas DWC069 form, officially known as the Report of Medical Evaluation, is a critical document within the Texas Department of Insurance Division of Workers’ Compensation. It is used by designated doctors to report on an injured employee's maximum medical improvement (MMI) and any permanent impairment resulting from a work-related injury. This form plays a pivotal role in determining the benefits an injured worker may receive. To ensure your rights are protected and you understand the implications of this report, consider filling out the form by clicking the button below.
The Texas DWC069 form, issued by the Texas Department of Insurance Division of Workers’ Compensation, is a crucial document for managing and understanding the medical status of employees who have suffered work-related injuries. Embedded within its structure, the form serves multiple pivotal roles: it collates general information about the employee, the employer, and the insurance carrier; outlines the responsibilities and findings of the involved medical professionals; and documents the evaluation of the employee’s Maximum Medical Improvement (MMI) and any permanent impairment resulting from the work-related injury. It is specifically designed for use by physicians who are either the treating doctor, a doctor selected by the treating doctor, a designated doctor selected by the DWC, or an insurance carrier-selected RME doctor, each authorized under specific conditions to evaluate MMI and assign permanent impairment ratings. Additionally, the form is an essential part of the process for ensuring accurate and timely communication between all parties involved in a workers’ compensation claim, including the insurance carriers, the Division of Workers' Compensation, and, most importantly, the injured employee and their representative. By detailing the process for filing the form, highlighting its importance in the event of disagreements over MMI or impairment ratings, and providing a clear path for dispute resolution, the DWC069 form underscores Texas’ commitment to the fair treatment of workers injured on the job while clarifying the procedural aspects of managing such cases. Its utility is further emphasized by its necessity in the documentation and validation of medical evaluations related to workers’ compensation claims.
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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Completing the Texas DWC069 form, known as the Report of Medical Evaluation, is a structured process that requires attention to detail. This form plays a critical role in documenting an injured employee's medical evaluation for workers' compensation claims. Filling out this form accurately ensures that the assessment of Maximum Medical Improvement (MMI) and any permanent impairment are officially recorded. Below are steps to guide you through completing the form.
After completing the Texas DWC069 form, it's crucial to file it properly. This involves sending it to the insurance carrier, the treating doctor (if someone other than the treating doctor completed the form), DWC, the injured employee, and the injured employee's representative, if applicable. Fax or email are the preferred methods for filing, ensuring compliance and timely processing.
The DWC Form-069 can be filed by several types of doctors, each playing a unique role in the workers' compensation process. Eligible doctors include:
The DWC Form-069 must be filed within seven working days following the scenario that occurs last: either the date of the certifying examination or after all necessary medical information required to certify MMI has been received. This strict timeline ensures timely processing and resolution of workers' compensation claims. It's crucial for designated doctors to adhere to this requirement, especially if the employee has not yet reached MMI.
The completed DWC Form-069 and any accompanying narrative should be submitted to several key parties to ensure full compliance and transparency in the workers' compensation process. These parties include:
If an injured employee disagrees with the MMI certification or the permanent impairment rating assigned by the doctor, they have the right to dispute these findings. This process includes contacting a local DWC field office or calling the designated help number to either request the appointment of a designated doctor (if one hasn't been appointed yet) or to schedule a Benefit Review Conference (BRC). It's important to note that disputes must be filed within 90 days from when the written notice of the MMI certification and/or impairment rating is delivered. Failure to file a dispute within this timeframe may result in the certification or rating becoming final.
Not verifying eligibility for filing the form: Filling out the DWC069 form without confirming if the doctor is authorized under 28 Texas Administrative Code §130.1 to certify MMI and assign an impairment rating is a common mistake. This negligence can lead to the invalidation of the certification.
Omitting vital information: Neglecting to provide complete details for sections such as the injured employee's name, DWC Claim #, or Carrier Claim # can result in processing delays or rejection of the form.
Incorrectly indicating the doctor’s role: Each doctor involved has a specific role, and accurately indicating whether they are the Treating Doctor, Doctor selected by Treating Doctor, Designated Doctor, or Insurance Carrier-selected RME Doctor is crucial for the processing of the report.
Failing to specify MMI correctly: Misinterpreting or improperly documenting whether the employee has reached Clinical or Statutory MMI can significantly impact the case's outcome. It's vital to mark this section accurately based on the medical evaluation.
Overlooking the documentation requirement: Not attaching the necessary narrative documentation to support the MMI certification or the impairment rating calculation can lead to the report being considered incomplete.
Incorrect impairment rating: Misinterpreting the guidelines for assigning an impairment rating or using an incorrect edition of the American Medical Association (AMA) Guides can lead to errors in the impairment rating assigned.
Delay in filing: The DWC069 form needs to be filed no later than the seventh working day after the certifying examination or after receiving all necessary medical information. Delaying beyond this timeframe can complicate the claim process.
Improper filing method: The form should be filed via fax or electronic transmission with the insurance carrier, treating doctor, DWC, injured employee, and the injured employee’s representative, if any. Choosing an incorrect method can delay its processing.
When managing workers' compensation claims in Texas, several forms and documents can be integral to supporting or providing additional context to the DWC069 form, Report of Medical Evaluation. These documents ensure a comprehensive approach to managing the claim, facilitating communication between all parties involved, and ensuring that the injured employee receives the appropriate evaluation and benefits.
These documents and forms complement each other in the administration and resolution of a workers' compensation claim. From the initiation of a claim with the DWC001 form to the resolution stages where disputes might arise and require a DWC025 or DWC045 form, each document plays a crucial role in ensuring fair and thorough evaluation and compensation for injured employees. Understanding and correctly utilizing these forms can significantly affect the outcomes for both employees and employers in the workers' compensation claims process.
The Texas DWC069 form, or Report of Medical Evaluation, has clear similarities with the First Report of Injury (FROI) often used in workers' compensation claims. Both documents serve as initial steps in the documentation process; the DWC069 aims to assess medical status, maximum medical improvement (MMI), and possible impairment, while the FROI informs the insurer or responsible party about an injury. Both require detailed information about the injured employee, the nature of the injury, and the medical provider's assessment, facilitating the administrative processing of workers' compensation claims.
Another document that shares similarities with the DWC069 form is the Request for Designated Doctor Examination form in Texas. This request form is used when there's a dispute in the assessment of MMI or impairment rating, paralleling the DWC069's function to report such evaluations. While the DWC069 documents the outcomes of medical evaluations, the Request form triggers the process by nominating a neutral third-party doctor to make impartial medical evaluations, reflecting a sequential relationship between identifying disputes and documenting medical conclusions.
The Return-to-Work (RTW) form, although primarily aimed at documenting an injured employee's capacity to resume work, shares elements with the DWC069. Both require a doctor's certification; the DWC069 for MMI and impairment, and the RTW to outline specific work restrictions or capabilities. The RTW form complements the DWC069 by using the medical evaluation to facilitate the employee's transition back to employment, underlining their interconnected roles in managing injury cases.
Similarly, the Employee’s Claim for Compensation for a Work-Related Injury or Occupational Disease (DWC Form-041) parallels the DWC069. While the DWC Form-041 serves as an official notification by the employee to claim workers' compensation benefits, the DWC069 form is used within the evaluative and diagnostic phase of the claim. Both forms are integral in the Texas workers’ compensation system, marking different stages—initiation and medical evaluation—within the claim process.
The Work Status Report shares a purpose with the DWC069, as both inform about the medical condition related to a workplace injury. However, the Work Status Report focuses more on the immediate work capabilities of the employee, providing guidance on work restrictions or modifications. In contrast, the DWC069 is utilized to document a more detailed medical evaluation, including MMI and impairment ratings. Together, they offer a comprehensive picture of the employee's medical status and work capacity.
Another analogous document is the Preauthorization Request Form for health services, often part of workers' compensation processes. Like the DWC069, it necessitates medical provider input to justify certain treatments or evaluations. The DWC069 provides the outcome of such evaluations, especially concerning MMI and impairment, while preauthorization forms seek approval to proceed with recommended medical interventions. Both are critical in managing the quality and extent of care within workers' compensation cases.
The Benefit Review Conference (BRC) Report also correlates with the DWC069. The BRC process attempts to resolve disputes that might arise from the evaluations reported in DWC069, such as disagreements about MMI or impairment ratings. While the DWC069 form captures the medical assessment's specifics, the BRC Report outlines the dispute resolution's procedural outcomes, marking a step towards resolving disagreements within the compensation claim process.
Finally, the Impairment Income Benefits (IIBs) Claim form relates closely to the information provided in the DWC069. IIBs hinge on the established impairment rating, a key component of the DWC069's purpose. Thus, the completion of the DWC069 form directly impacts the calculation and eligibility for IIBs, linking the medical evaluation's outcomes to the financial aspects of the compensation claim.
In summary, the Texas DWC069 form is integral to the workers’ compensation system, intersecting with various other documents at different stages of a claim. From initiating a claim, through medical evaluation, to dispute resolution and determination of benefits, its relevance extends throughout the entire process, ensuring objective and documented medical assessments guide recovery, return to work, and compensation outcomes.
When dealing with the Texas Department of Insurance Division of Workers' Compensation Report of Medical Evaluation (DWC069 form), attention to detail and adherence to procedures are paramount. The following list includes essential do's and don'ts to ensure the process is handled correctly and efficiently.
Filling out the DWC069 form with care and adherence to these guidelines is crucial for the fair and efficient processing of workers' compensation claims in Texas. Proper completion helps to ensure that injured employees receive the right benefits in a timely manner, avoiding unnecessary disputes or delays.
There are several misconceptions about the Texas Department of Insurance Division of Workers’ Compensation Report of Medical Evaluation, also known as the DWC069 form. Understanding these misconceptions is crucial for parties involved in workers’ compensation claims in Texas.
This is incorrect. Only doctors in specific roles such as the treating doctor, a doctor selected by the treating doctor, a designated doctor selected by the DWC, or an insurance carrier-selected RME doctor authorized by the DWC can complete this form.
In fact, the form has broader uses, including certifying maximum medical improvement (MMI) and documenting permanent impairment, not just the impairment rating itself.
There are specific deadlines for submission. The form must be filed no later than the seventh working day after the later of the certifying examination or receipt of all medical information necessary to certify MMI.
This statement is not entirely accurate. While the form and required narrative can be mailed, they must generally be filed by facsimile or electronic transmission unless an exception applies.
The form can indeed be filed by email, along with facsimile or other verifiable means, provided the recipient has not provided alternative electronic transmission numbers.
Incorrect. The form should be filed with the insurance carrier, the treating doctor (if a different doctor fills out the report), the injured employee, the DWC, and the injured employee’s representative (if any).
In reality, the certifying doctor must sign the form to confirm the accuracy and completeness of the report, certifying it complies with the Texas Labor Code and applicable rules.
These are distinct concepts. Clinical MMI refers to the point where no further recovery is anticipated, whereas Statutory MMI is related to specific timelines in the Texas Labor Code.
This is a misunderstanding. A 0% impairment rating indicates there is an impairment, but it does not significantly limit the employee's functionality according to the guides used for evaluation.
Actually, reaching MMI does not signify the end of entitlement to medical benefits. Employees can continue to receive necessary medical care related to the compensable injury.
Understanding the complexities of the Report of Medical Evaluation, known colloquially as the DWC069 Form, demands a focus on key aspects crucial for those involved in the process of workers' compensation claims in Texas. Here are several key takeaways:
Each of these points underscores the DWC069 form's integral role in the Texas workers' compensation system, both in terms of administrative procedure and in affecting the outcomes of injured workers' claims.
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