DWC053 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) 804-4378 fax Complete if known: DWC Claim # Carrier Claim # Employee Request to Change Treating Doctor For use ONLY by Employees NOT in Workers' Compensation Health Care Networks or Certain Political Subdivision Health Care Plans Type (or print in black ink) each item on this form I. EMPLOYEE/EMPLOYEE'S ATTORNEY INFORMATION 1. Employee's Name (First, Middle, Last) 3. Employee's Mailing Address (Street or PO Box, City, State, Zip Code) 4. Employee's Telephone Number ( ) 7. Attorney/Representative's Name (if applicable) 5. Alternate Telephone Number (if available) 6. Date of Injury (mm/dd/yyyy) ( ) 8. Attorney/Representative's Address (Street or PO Box, City, State, Zip Code) 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 Code) III. INSURANCE CARRIER INFORMATION 11. Insurance Carrier's Name 13. Adjuster's Name 12. Insurance Carrier's Address (Street or PO Box, City, State, Zip Code) 14. Adjuster's Telephone Number ( ) ext. 15. Adjuster's Fax Number ( ) IV. TREATING DOCTOR INFORMATION Current Treating Doctor 16. Current Treating Doctor's Name (First, Middle, Last) and Title (MD, DO, DC, etc.) 18. Current Treating Doctor's Mailing Address (Street or P.O. Box, City, State, Zip Code) 19. Current Treating Doctor's License Number (if known) 20. Current Treating Doctor's Fax Number ( ) 17. Current Treating Doctor's Telephone Number ( ) ext. Reason for Requesting a Change of Treating Doctor 21. Explain Why You Are Requesting to Change Your Treating Doctor (Attach additional sheets if necessary.) Requested Treating Doctor 22. Requested Treating Doctor's Name (First, Middle, Last) and Title (MD, DO, DC, etc.) 24. Requested Treating Doctor's License Number 26. Requested Treating Doctor's Mailing Address (Street or P.O. Box, City, State, Zip Code) 27. Requested Treating Doctor's Signature (required) 28. Date (mm/dd/yyyy) 23. Requested Treating Doctor's Telephone Number ( ) ext. 25. Requested Treating Doctor's Fax Number ( ) V. EMPLOYEE'S AUTHORIZATION TO CHANGE TREATING DOCTORS AND RELEASE MEDICAL RECORDS By signing this form I confirm that I wish to change my treating doctor, and I authorize my current treating doctor to furnish records pertaining to my workers' compensation claim to the requested treating doctor. 28. Employee's Signature (required) 29. Date NOTE: With few exceptions, upon your request, you are entitled to be informed about information TDI-DWC collects about you; receive and review the information (Government Code, §§552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government Code, §559.004). DWC053 Rev. 03/12 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com For TDI-DWC Use Only DWC053 Frequently Asked Questions Employee Request to Change Treating Doctor (DWC Form-053) For use ONLY by Employees NOT in Workers' Compensation Health Care Networks or Certain Political Subdivision Health Care Plans Who may use this form to change treating doctors? Only an injured employee (a) who is covered by the Texas workers' compensation system; (b) who has a claim with a date of injury or exposure on or after January 1, 1991; (c) who is not part of a c ertified workers' compensation health care network (network); and (d) whose claim does not involve medical benefits provided through a political subdivision (political subdivision health plan) pursuant to §504.053(b)(2) of the Texas Labor Code, relating to directly contracting with health care providers or contracting through a health benefits pool may use this form to request a change of treating doctor. NOTE: If you are in a network described in (c) above or a health plan described in (d) above, contact the network or health plan and follow their procedures for changing your treating doctor. If you do not know if you are in a network or this type of health plan, contact your workers' compensation insurance adjuster. Under what circumstances am I required to file the DWC Form-053? You must file the DWC Form-053 to request Texas Department of Insurance, Division of Workers' Compensation (TDIDWC) approval before receiving services from a new treating doctor if you are dissatisfied with the initial choice of treating doctor for a valid reason including, but not limited to: · you believe treatment provided by your current treating doctor is medically inappropriate; · you believe you are not receiving appropriate medical care to reach maximum medical improvement; · you are concerned about the professional reputation of your current treating doctor; · there is a conflict between you and your current treating doctor to the extent that the doctor-patient relationship is jeopardized or impaired; or · your current treating doctor chooses not to coordinate your health care because of communication issues between the doctor and the insurance carrier regarding the processing of your medical bills. Provide documentation from your current treating doctor, if available. You may not request a change of treating doctor to obtain a new impairment rating or medical report. IMPORTANT NOTE: If you fail to obtain TDI-DWC approval prior to receiving treatment from the new treating doctor, you may be responsible for the cost of treatment and the insurance carrier may be relieved of responsibility for payment. In order to obtain TDI-DWC approval, you must file the DWC Form-053 unless an immediate change of treating doctor is medically necessary. In that case, you may contact the TDIDWC field office handling your claim by telephone to obtain verbal approval. You must also file the DWC Form-053 to immediately notify the TDI-DWC if you change treating doctors because: · you moved or changed residence; or · your current treating doctor is unavailable or unable to provide medical care or has retired or died. Provide documentation from the doctor's office, if available. Why is the new treating doctor's signature required? You must confirm that the requested doctor will treat you by contacting the requested doctor's office, describing your injury and asking if the doctor is taking new workers' compensation patients. To verify that the doctor has agreed to treat you, you must have the doctor sign the DWC Form-053 in Box 27. The treating doctor must be a do