Texas Department Of Insurance DWC Claim# Division of Workers’ Compensation 7551 Metro Center Dr. Ste.100 • MS-603 Austin, TX 78744-1609 (800) 252-7031 (512) 804-4121 fax www.tdi.state.tx.us Carrier Claim# REQUEST FOR DESIGNATED DOCTOR (DWC Form-032) Type (or print in black ink) each item on this form. I. INJURED EMPLOYEE INFORMATION 1. Injured Employee Name 2. Date of Birth (Last, First, M.I.) (mm-dd-yyyy) 4. Date of Injury 6. Address 5. Date of Statutory MMI (mm-dd-yyyy) 3. Social Security # (mm-dd-yyyy) 7. County (Street or P.O. Box, City, State, Zip) 8. Primary Telephone Number 9. Alternate Phone / Cell Phone Number 10. Fax Number 11. E-mail Address 12. Representative’s Name (if any) 13. Representative’s Telephone Number 14. Representative’s Fax Number II. EMPLOYER INFORMATION 15. Employer’s Name 16. Address (Street or P.O. Box, City, State, Zip) III. TREATING DOCTOR/NETWORK INFORMATION 17. Treating Doctor's Name and License Type 18. License Number 19. Address (Street or P.O. Box, City, State, Zip) 20. Telephone Number 21. Fax Number 22. Workers' Compensation Health Care Network (if any) IV. INSURANCE CARRIER INFORMATION 23. Insurance Carrier Name 24. Adjuster's Name 25. Address 26. Adjuster's E-mail Address (Street or P.O. Box, City, State, Zip) 27. Adjuster's Telephone Number and extension (if any) 28. Adjuster's Fax Number V. OTHER INFORMATION 29. Requester of Exam Injured Employee Injured Employee Representative Insurance Carrier TDI-DWC/DWC Medical Advisor Requesters of a designated doctor exam are encouraged to provide a copy of the completed DWC Form-032 to all parties at the time the original Request is submitted to TDI-DWC. DWC032 Rev. 11/08 American LegalNet, Inc. Page 1 www.FormsWorkflow.com DWC Claim# Carrier Claim# VI. REASON FOR REQUEST **NOTE TO THE DESIGNATED DOCTOR** Address only those issues that are checked. Do not address additional issues unless specifically requested to do so. A. Maximum Medical Improvement (MMI) Instructions for the Requester: If you are disputing a previously certified MMI date, the following information is required: Date of MMI (mm/dd/yyyy) Date of certification (mm/dd/yyyy) ______ Name of the certifying doctor ______ RME doctor _____ treating doctor Question for the Designated Doctor to consider in the exam: Has MMI been reached; and, if so, on what date? (NOTE: MMI may not be th greater than the Statutory MMI date provided in Box 5. This date is 104 weeks after the 8 day of disability.) B. Impairment Rating (IR) Instructions for the Requester: If you are disputing a previously assigned IR, the following information is required: Date of MMI (mm/dd/yyyy) ______ Name of the certifying doctor Date of certification (mm/dd/yyyy) ____ RME doctor ______ IR assigned treating doctor Question for the Designated Doctor to consider in the exam: As of the certified MMI date, what is the Impairment Rating (IR)? (NOTE: If clinical MMI has not been reached, it is mandated by law to assign an IR based on the injured employee's condition on the statutory MMI date given in I. EMPLOYEE INFORMATION, item 5.) C. Extent of Injury The information below is required. Instructions for the Requester: 1. Describe the accident or incident that caused the claimed injury. 2. List all compensable injuries (diagnosis, body parts, and/or conditions) not in dispute. 3. List all disputed injuries (diagnosis, body parts, and/or conditions) claimed to be a cause of or naturally resulting from the accident or incident. Questions for the Designated Doctor to consider in the exam: Was the accident or incident giving rise to the compensable injury a cause of the additional claimed injuries or conditions? Do the claimed injuries or conditions naturally arise from the compensable injuries? D. Disability – Direct Result Only check this box if the injured employee is not working or the injured employee is earning less than pre-injury wages. The information below is required. Instructions for the Requester: 1. Provide the beginning and ending dates for the claimed periods of disability. (Required) From 2. ____________ _ mm/dd/yyyy to _____________ mm/dd/yyyy (if multiple periods, list all dates). List all compensable injuries (diagnosis, body parts, and/or conditions). Question for the Designated Doctor to consider in the exam: Is the employee's inability to perform the pre-injury employment a direct result of the compensable injury? DWC032 Rev. 11/08 Page 2 American LegalNet, Inc. www.FormsWorkflow.com DWC Claim# Carrier Claim# VI. REASON FOR REQUEST (CONTINUED) E. Return to Work Instructions for the Requester: If you wish to know the injured employee’s current ability to return to work in any capacity, the following is not needed. 1. Provide the beginning and ending dates for each period covered by this Request. (Optional) From 2. ____________ _ mm/dd/yyyy to _____________ mm/dd/yyyy (if multiple periods, list all dates). If you wish to offer the injured employee a specific job or jobs, provide a brief job description(s) for the job(s) available for the injured employee. (Optional) Question for the Designated Doctor to consider in the exam: Is the injured employee able to return to work in any capacity and what work activities can the injured employee perform? F. Return to Work for Supplemental Income Benefits (SIBs) Only check this box for return to work for an injured employee entitled to Supplemental Income Benefits (SIBs). NOTE: Injured employees are allowed only one designated doctor exam a year after the th second anniversary (8 quarter) of SIBs. The information below is required. Instructions for the Requester: 1. Provide the beginning and ending dates for each qualifying period covered by this Request. From 2. ____________ _ mm/dd/yyyy to _____________ mm/dd/yyyy (if multiple periods, list all dates). Is the above qualifying period(s) applicable to the 9th quarter (or greater) of supplemental income benefits? YES NO Question for the Designated Doctor to consider in the exam: Has the injured employee’s medical condition improved sufficiently to allow the employee to return to work in any capacity for the identified qualifying period(s)? Please explain. G. Other Similar Issues Designated Doctor examinations may not be requested for developing treatment plans, determining the appropriateness of medical care, or to determine the compensability of the injury. Instructions for the Requester: Identify the issue(s) and provide sufficient detail for the designated doctor to address the issue(s). (Required.) Example: To determine if there is an injury resulting from the claimed incident. DWC032 Rev. 11/08 Page 3 American LegalNet, Inc. www.FormsWorkflow.com INJURY AND TREATMENT INFORMATION: TDI-DWC is required to obtain the following information to select a designated DWC Claim #: doctor. If you have any questions or difficulties providing any of this required information, contact TDI-DWC at 800-252-7031 Carrier Claim #: for assistance. If you are unsure of the injured employee’s condition or treatment history contact the treating doctor. General Treatment Types – Check off each type of treatment received on each injury area that is part of or claimed to be a Injury Areas – Check off each injury part of the injury and indicate if the treatment has been suspended or discontinued.1 area that is part of or claimed to be VII. part of the injury. Note: Each injury area MUST be checked, even if NO treatment has been provided. Physical Medicine Check if provided Check if discontinued Prescription Medication Therapeutic Injections Check if used Check if given Check if discontinued Check if discontinued Surgery Check if performed Behavioral Medicine Check if released by 2 Surgeon Check if provided Check if discontinued Musculoskeletal Injuries: Back and Neck Hand and Upper Extremities Lower Extremities and Feet Occupational Exposures and Injuries: Central Nervous System (Cerebrum/Forebrain) Brain Stem Spinal cord or spinal canal Muscular and Peripheral Nervous System Respiratory System Cardiovascular System Hematopoietic System (blood disorders) Eyes Ears Face Teeth Nose, Throat and Related Structures Digestive System Urinary and Reproductive Systems Endocrine System (hormone system) Skin Mental and Behavioral Disorders Mental and Behavioral Disorders Chronic pain GENERAL CATEGORIES OF TREATMENT DEFINITIONS Physical Medicine – Non-invasive treatment that involves manual movements of the affected body part. This includes treatments such as massage, myofascial release, physical therapy, manipulations, mobilizations, acupuncture, work hardening, work conditioning, etc. Prescription Medication – Medication that must be obtained from a pharmacist or the prescribing doctor and that cannot be obtained without a doctor’s prescription. Therapeutic Injections – Includes treatments such as epidural and trigger point injections and does not include minor/routine injections such as tetanus shots, allergy shots, or IVs. Surgery – An operation or other invasive treatment often performed at a hospital. This does not include minor procedures such as treating minor cuts or lacerations. Behavioral Medicine – Includes treatments such as psychiatry, psychological testing and counseling, biofeedback and related disciplines. th Each Injury Area includes the conditions/body parts/systems listed in the corresponding section or chapter of the 4 Edition of the AMA Guides to the Evaluation of Permanent Impairment. If it is unclear which row should be selected for a given condition, consult the AMA Guides to determine which section contains the methodology for rating impairment for the condition. Example - hernias are covered under “Digestive System” because that is the chapter that contains instructions on how to assign an impairment rating for a hernia. NOTICE: Providing incorrect or inaccurate information regarding this Request could cause an incorrect selection of the designated doctor and may result in enforcement action including administrative penalties and fines. 1 – Indicating that a treatment has been discontinued is NOT a statement that further treatment of that sort is not medically necessary or that it will not resume at some point. Rather, it is a statement that at the time the Request for a designated doctor is made, the injured employee is not actively receiving that treatment. 2 – A surgeon is considered to have released the injured employee after surgery when the injured employee has completed all follow-up visits required to verify the injured employee’s recovery from the surgery. It does not mean that the injured employee has been released to return to work, been released from all medical treatment, or reached MMI. DWC032 Rev. 11/08 Page 4 American LegalNet, Inc. www.FormsWorkflow.com Instructions for Completing the Request for Designated Doctor (DWC Form-032) For more information contact your local TDI-DWC Field Office at 800-252-7031. Who may request that a designated doctor examination be ordered? The injured employee, the injured employee's representative, or the insurance carrier may request the Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) to order a designated doctor examination. A designated doctor examination may not be performed more than once every 60 days. TDI-DWC may approve additional Requests for an examination within the 60-day period if good cause exists. TDI-DWC may also order a designated doctor examination on its own motion. For what purposes may a designated doctor exam be requested? To resolve questions about: A. maximum medical improvement; B. impairment rating; C. extent of injury; D. whether the injured employee’s disability is a direct result of the work-related injury; E. ability of the injured employee to return to work; F. return to work for Supplemental Income Benefits (SIBs); or G. issues similar to those described above. Designated doctor examinations may not be requested for developing treatment plans, determining the appropriateness of medical care, or for determining the compensability of the injury. How do I fill out the Request for Designated Doctor? DWC encourages you to type the Request for Designated Doctor (Request). If necessary, print clearly in black ink each item on this form. Unclear Requests will be returned to you. Failure to provide required information and all pages (pages 1-4) will cause a delay in processing and your Request will be returned to you. Please provide the DWC claim number on each page and the Carrier claim number, if known (top of page). Providing incorrect or inaccurate information regarding this Request could cause an incorrect selection of the designated doctor and may result in enforcement action including administrative penalties and fines. You are encouraged to provide a copy of the completed Request to all parties at the time it is submitted to TDI-DWC. Attachments to the form (PLN’s, DWC69s, etc.) or supplemental pages will not be accepted with the Request. There is ample space on the form for you to provide necessary information. Note: A Request for Designated Doctor may not be submitted to dispute or disagree with a designated doctor assessment. If you would like to dispute a designated doctor's assessment, please submit a Request for Benefit Review Conference (DWC Form-45). Page One Complete ALL information. If information is not applicable, type “NA” (examples: alternate phone number or fax number for injured employee may not exist). Failure to complete this page will result in the TDI-DWC returning your Request to you. Section I. Box 5, Date of Statutory MMI, must be completed if the injured employee has accrued at least 8 days of disability. Statutory MMI is 104 weeks after the 8th day of disability. If the injured employee has not accrued 8 days of disability, put “NA” for not applicable or “NLT” for no loss time. Section III. If the injured employee does not have a treating doctor, you may specify “No Treating Doctor” in the space provided for the doctor’s name. Leaving this section blank or failure to complete all information will result in the TDI-DWC returning your Request to you. DWC032 Rev. 11/08 American LegalNet, Inc. www.FormsWorkflow.com Instructions Page Two If you are disputing a previously certified MMI and/or IR, Box A and/or B must be completed. Failure to complete required information will result in the TDI-DWC returning your Request to you. If maximum medical improvement and impairment rating have not been previously certified by a doctor, Box B cannot be requested without Box A. Box D – the “claimed period of disability” in question #1 cannot include a future date. You may provide “present” for the ending date. Page Three Box E – periods covered in question #1 cannot include a future date. You may provide “present” for the ending date. If offering a specific job or jobs, you may provide a brief job description(s) in the space provided. No attached job descriptions will be accepted. Box F – check this box for return to work for an injured employee entitled to Supplemental Income Benefits (SIBs). You may not request future qualifying periods. Page Four Requests will not be accepted without the completed Page Four (Matrix). Providing incorrect or inaccurate information regarding this Request could cause an incorrect selection of the designated doctor and may result in enforcement action including administrative penalties and fines. Check the applicable box(es) on the left of Matrix for each injury area that is part of or claimed to be part of the injury, even if no treatment has been provided. Where do I send the completed Request? Send the original, completed form to TDI-DWC at: Texas Department of Insurance Division of Workers’ Compensation Designated Doctor Scheduling Section 7551 Metro Center Dr., Suite 100 • MS-603 Austin, TX 78744-1609 or FAX to (512) 804-4121 What does TDI-DWC do? TDI-DWC Designated Doctor Scheduling (DDS) Section will review the Request to ensure its completeness and accuracy, and review the claim file history to verify the Reasons for Request are valid. If the Request is approved, the DDS Section will assign a qualified Designated Doctor (DD) to examine the injured employee. If there is a previously assigned Designated Doctor to the claim, the same doctor will be used as long as the doctor is still qualified and available. Within 10 days after approval, TDI-DWC will issue an order to the parties regarding the exam. If the Request should be returned to you, you will receive a Notice of Returned Request for DD providing you with the specific reason(s) the TDI-DWC was unable to process your Request. Where do I find more information on the designated doctor process? Resources that answer common questions about the designated doctor process are available online at http://www.tdi.state.tx.us/wc/hcprovider/dd.html. NOTE: With few exceptions, you are entitled on request to be informed about the information that TDI-DWC collects about you. Under §§552.021 and 552.023 of the Government Code, you are entitled to receive and review the information. Under §559.004 of the Government Code you are entitled to have TDI-DWC correct information about you that is incorrect. For more information, call the local TDI-DWC field office at 800-252-7031. DWC032 Rev. 11/08 American LegalNet, Inc. www.FormsWorkflow.com Instructions