Texas Department Of Insurance Division of Workers’ Compensation DWC Claim# Carrier Claim# Chief Clerk of Proceedings 7551 Metro Center Dr. Ste.100 • MS-35 Austin, TX 78744-1609 (512) 804-4010 (512) 804-4011 fax www.tdi.state.tx.us REQUEST FOR A BENEFIT REVIEW CONFERENCE (DWC Form-045) I hereby request a Benefit Review Conference be scheduled in ___________________________ (location) 1. Employee's Name (Last, First M I) 2. Social Security Number xxx-xxThe Benefit Review Conference will be conducted at a location no more than 75 miles from the claimant's residence at the time of the injury, unless the Division determines that good cause exists for the selection of a different location. 3. Date of Injury 4. Insurance Carrier's Name 5. Employer's Business Name Check applicable box(es): 1. Carrier selected doctor has released injured employee to return to work (medical report attached). 2. Disputing the findings of the designated doctor on Maximum Medical Improvement or impairment. 3. Carrier selected doctor has certified that the injured employee has reached Maximum Medical Improvement (medical report has not attached). The injured employee's treating doctor, Dr. , disagrees with the certification or has not responded, and a request for a designated doctor has been previously made to the Division or a request is attached. 4. Requested as provided in Rule 130.4, Titled Presumption That Maximum Medical Improvement Has Been Reached, based on an apparent lack of medical improvement or abandonment of medical treatment. (A request for a required medical examination or a request for a designated doctor must be attached if the carrier alleges the presumption of Maximum Medical Improvement or if the lack of medical improvement is identified.) 5. Contesting the determination of entitlement to or amount of Supplemental Income Benefits or whether the injured employee's underemployment is a direct result of the impairment. 6. Employer contesting compensability after the insurance carrier has accepted liability. 7. Other (Explain) Briefly describe each unresolved issue and discuss resolution attempts. ___________________________________________________ (Additional pages may be attached) 8. An expedited Benefit Review Conference. 9. Special accommodations are needed (Does not speak English, has a physical, mental or developmental handicap) please describe: Requested By: Employee Carrier Employer Subclaimant Beneficiary Attorney for By my signature below, I certify that a good faith effort has been made to resolve the issues identified above. Requester's Signature _ Requester's Typed or Printed Name Requester's Mailing Address Phone No. ( ) ________________________________________________________________________________ Date of Request _________________ __ cc: Carrier or Employee/Representative DWC FORM-045 Rev. 10/05 Page 1 DIVISION OF WORKERS’ COMPENSATION American LegalNet, Inc. www.FormsWorkFlow.com DWC FORM - 45 (Request for a Benefit Review Conference) A party to a claim is entitled to file a Request for a Benefit Review Conference (DWC FORM-045) with the Texas Department of Insurance, Division Workers' Compensation in order to mediate and resolve disputed issues. An unrepresented claimant may request a benefit review conference by contacting the Texas Department of Insurance, Division of Workers' Compensation in any manner and is not required to file this form. The Texas Department of Insurance, Division of Workers' Compensation will schedule the conference to be held within 40 days of the filing date of the request, or within 20 days if an expedited conference is requested and warranted. The conference will be conducted at a site no more than 75 miles from the claimant's residence, at the time of the injury, unless the Division determines that good cause exists for the selection of a different location. The DWC FORM-045 is considered filed when received by the Texas Department of Insurance, Division of Workers' Compensation or when personally delivered to the Texas Department of Insurance, Division of Workers' Compensation. The form should be filed with the Field Office handling the claim. Failure to file the form with the appropriate field office may delay processing. [Texas Labor Code, Sec. 410.021, 410.023-.025/410.028 Request for Benefit Review Conference ; Rule 141.1] 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. DWC FORM-045 Rev. 10/05 Page 2 DIVISION OF WORKERS’ COMPENSATION American LegalNet, Inc. www.FormsWorkFlow.com