DWC022 Texas Department of Insurance Division of Workers' Compensation 7551 Metro Center Drive, Suite 100 x MS-94 Austin, TX 78744-1645 (800) 252-7031 phone x (512) 804-4378 fax Si desea hablar con alguien sobre este formulario o acerca de su reclamación, llame al ajustador de su aseguradora al número de teléfono que aparece en la Casilla 15 de la Sección III. Complete if known: DWC Claim # 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) 3. Employee's Address (Street or PO Box, City State Zip) 4. Employee's Telephone Number ( ) 7. Attorney/Representative's Name (if applicable) 6. Date of Injury (mm/dd/yyyy) 5. Alternate Telephone Number (if available) ( ) 8. Attorney/Representative's Address (Street or PO Box, City State Zip) 2. Employee's Social Security Number 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 14. Adjuster's E-mail 12. Insurance Carrier's Address (Street or PO Box, City State Zip) 15. Adjuster's Telephone Number ( ) ext. 16. Adjuster's Fax Number ( ) 13. Adjuster's Name 17. Adjuster's License Number 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 23. Date and Time of Appointment Yes No If yes, provide the name of the network. 21. RME Doctor's Telephone Number 22. Examination Location (Street, City State Zip) ( ) 24. Does the claim involve medical benefits provided through a Certified Health Care 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 Yes No directly contracting with health care providers or contracting through a health benefits pool? 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: x This request is complete and accurate. x The insurance carrier will pay reasonable expenses incident to the examination of the injured employee. x The selected doctor does not have a disqualifying association. x 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. x 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 32. Printed Name of Adjuster or Authorized Insurance Carrier Representative 33. Title of Adjuster or Authorized Insurance Carrier Representative 34. Date of Signature For TDI-DWC Use Only DWC022 Rev. 07/11 American LegalNet, Inc. www.FormsWorkFlow.com 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 38. RME Doctor's Telephone Number ( ) 41. Date of Prior Examination 36. RME Doctor's Mailing Address (Street or PO Box, City State Zip) 39. Examination Location (Street, City State Zip) 42. Prior Examining Doctor's Name 37. RME Doctor's License Number 40. Date and Time of Appointment 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 Yes No directly contracting with health care providers or contracting through a health benefits pool? 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: x x 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) x x x 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 50. Printed Name of Adjuster or Authorized Insurance Carrier Representative 49. Date of Signature 51. Title of P