DWC032 DWC032 Rev. 10/18 Page 1 of 6 Complete, if known: DWC Claim # Carrier Claim # Request for Designated Doctor Examination Type (or print in black ink) each item on this form I. INJURED EMPLOYEE INFORMATION 1. Employee Name ( First, Middle , Last ) 2. Employee Social Security Number 3. Employee Address (Street or P.O. Box, City, State, Z IP Code) 4. Employee County 5. Employee Primary Phone Number ( ) 6. Employee Alternate Phone Number ( ) 7. Employee Date of Birth (mm-dd-yyyy) 8. Date of Injury (mm-dd-yyyy) 9 . Representative222s Name (First, Middle, Last) 10 . Representative222s Phone Number ( ) 11 . Representative222s Email Address 12 . Representative222s Fax Number ( ) 13 . Employer Name 14 . Employer Phone Number ( ) 15 . Employer Address (Street or P.O. Box, City, State, ZIP Code) II. INSURANCE CARRIER INFORMATION 16 . Insurance Carrier Name 1 7 . Insurance Carrier Address (Street or P.O. Box, City, State, Z IP Code) 18 . Adjuster Name (First, Middle, Last) 1 9 . Adjuster Email Address 20 . Adjuster P hone Number ( ) 21 . Adjuster Fax Number ( ) 22 . Does the claim involve medical benefits provided through a Certified Workers222 Compensation Health Care Network? Yes No If yes, provide the name of the network. 23 . Does the claim involve medical benefits provided through a political subdivision under Labor Code 247504.053(b)(2), directly contracting with health care providers or contracting through a health benefits pool? Yes No Only Insurance Carriers Complete Boxes 24 - 28 24 . Insurance Carrier222s Authorized Agent Company Name 25 . Insurance Carrier222s Bill Review Agent Name 26 . Bill Review Agent Phone Number ( ) 27 . Bill Review Agent Fax Number ( ) 28 . Bill Review Agent Address (Street or P.O. Box, City, State, Z IP Code) For DWC Use Only American LegalNet, Inc. www.FormsWorkFlow.com DWC032 DWC032 Rev. 10/18 Page 2 of 6 III. TREATING DOCTOR INFORMATION 29 . Treating Doctor Name 30 . Treating Doctor P hone Number ( ) 31 . Treating Doctor Address (Street or P.O. Box, City, State, Z IP Code) 32 . Treating Doctor Fax Number ( ) 33 . Treating Doctor License Number 34 .Treating Doctor License Type IV. DESIGNATED DOCTOR SELECTION INFORMATION 35. Check all body areas and diagnoses that apply: Examples (not an exhaustive list) Spine and Musculoskeletal Structures of Torso *See below for spinal cord injuries, hernia Cervical, Thoracic, or Lumbar Re gions, Herniated Disc, Rib Cage, Chest Wall, Abdominal Wall, Sprains or S trains Upper Extremities Shoulder, Forearm, Arm, Elbow, Wrist, Hand, Finger Regions, Rotator Cuff Tear , Sprains or Strains Lower Extremities (excluding feet) * See below for multiple fractures, hip or pelvis fracture . Butt ock, Thigh, Leg, Knee Regions, ACL Tear, Meniscus Tear , Sprains or Strains Feet Toes, Heel Teeth and Jaw Temporomandibular Joint (TMJ) Eyes Eyelid , Foreign Body, Corneal Abrasion Other Body Areas or Systems Ear, Nose, an d Throat ; Head and Face; Skin; Cuts to Skin involving Underlying Structures; Non-Musculoskeletal Structures of the Torso; Hernia; Respiratory; Endocrine; Hematopoietic; Urologic Traumatic Brain Injury Concu ssion; Post - Concussion Syndrome Spinal Cord Injury Spinal F racture with documented neurological deficit; Cauda Equina Syndrome Severe Burns (including chemical burns) 2 nd , 3 rd , or 4 th Degree; Deep Partial, or Full Thickness Burns Multiple Fractures , Joint Dislocation, Hip or Pelvis Fracture N/A Infectious Diseases (complicated) Infection requiring hospitalization or prolonged intravenous antibiotics, including Blood Borne Pathogens Complex Regional Pain Syndro me N/A Chemical Expo sure N/A Heart or Cardiovascular Condition N/A Mental and Behavioral Disorders Post - Traumatic Stress Disorder (PTSD) Employee222s Name: DWC Claim Number: For DWC Use Only American LegalNet, Inc. www.FormsWorkFlow.com DWC032 DWC032 Rev. 10/18 Page 3 of 6 V. PURPOSE FOR EXAMINATION 3 6 . Requester: Check box(es) A through G next to the issue(s) you want the designated doctor to address and provide the requested information. A. Maximum Medical Improvement (MMI) Statutory MMI Date (if any) (mm/dd/yyyy) B. Impairment Rating (IR) MMI Date* ( required only if Box A is not checked) (mm/dd/yyyy) *The MMI date determined valid by a final DWC decision, court, or agreement of the parties. C. Extent of Injury List all injuries (diagnoses/body parts/conditions) in question, claimed to be caused by, or naturally resulting from the accident or incident and describe the accident or incident that caused the claimed injury. D. Disability 226 Direct Result Note: Check only if the injured employee is unable to obtain and retain employment at wages equivalent to the pre-injury wage Provide the claimed period o f disability . If multiple periods, list all dates . From to (mm/dd/yyyy) (mm/dd/yyyy) *Ending date cannot be a future date. Write 223present224, if no specific ending date. E. Return to Work Provide the period to be assessed . If multiple periods, list all dates . From to (mm/dd/yyyy) (mm/dd/yyyy) F. Return to Work (Supplemental Income Benefits) Note: Only one designated doctor examination per year after the second anniversary (8th quarter) of Supplemental Income Benefits is allowed Provide the period to be assessed . If multiple periods, list all dates . From to (mm/dd/yyyy) (mm/dd/yyyy) Is the qualifying period(s) applicable to the 9th quarter (or a subsequent quarter) of supplemental income benefits? Yes No G. Other Similar Issues Note: Designated doctor examinations may not be requested for developing treatment plans, determining appropriateness of medical care, or determining compensability Identify the issue(s) and provide sufficient detail for the designated doctor to address the issue(s). Employee222s Name: DWC Claim Number: For DWC Use Only American LegalNet, Inc. www.FormsWorkFlow.com DWC032 DWC032 Rev. 10/18 Page 4 of 6 VI. QUESTIONS FOR THE DESIGNATED DOCTOR Designated Doctor: Address issues that are i dentified in Section V of the form and consider the questions below. If Box A or B is checked, you must file DWC Form-069. If Box E or F is checked, you must file DWC Form-073. If Box C, D, or G is checked, you must file DWC Form-068. If Box A is checked , h as MMI been reached; if so, on what date (may not be greater than the statutory MMI date shown above)? If Box B is checked, o n the MMI date, what is the IR? If Box C is checked, w as the accident or incident giving rise to the compensable injury a substantial factor in bringing about the additional claimed injuries or conditions, and without it, the additional injuries or conditions would not have occurred? Include an explanation of the basis for your opinion. If Box D is checked, i s the employee's inability to obtain and retain employment at wages equivalent to the pre - injury wage a direct result of the compensable injury? If Box E is checked, i s the injured employee able to return to work in any capacity and what work activities can the injured employee perform? If Box F is checked, h as the injured employee222s medical condition improved sufficiently to allow the employee to return to work in any capacity for the identified qualifying period(s)? VII. EXAMINATION / INJURY INFORMATION 37 . List all injuries accepted as compensable by the insurance carrier. (Provide descriptions if using ICD codes.) 38 . List all injuries determined to be compensable by an Approved DWC Form - 024, DWC decision & order, DWC Appeals Panel decision, or final court order, if applicable. (Provide descriptions if using ICD codes.) 39. If approval of this request would result in the Texas Department of Insurance, Division of Workers222 Compensation (DWC) scheduling an examination within 60 days of a previous designated doctor examination, provide good cause as to why it is necessary to schedule this examination within 60 days. Employee222s Name: DWC Claim Number: For DWC Use Only American LegalNet, Inc. www.FormsWorkFlow.com DWC032 DWC032 Rev. 10/18 Page 5 of 6 VIII. REQUESTER CERTIFICATION 4 0 . Check the appropriate box: Injured Employee Injured Employee Representative Insurance Carrier I certify the following: I am authorized to request the examina