Can DWC Form 032 be e-signed?

Yes when the receiving claims administrator or insurer accepts electronic signatures. Electronic signatures are generally enforceable under the ESIGN Act (15 U.S.C. ch. 96, 2000) and UETA when applicable; verify any DWC-specific intake policies before e-signing.

What date format should I use?

Use MM/DD/YYYY for all dates on the form and attachments to ensure consistency with automated intake systems and to avoid ambiguity about incident and treatment timing.

Who must sign the form?

An authorized employer representative, claims adjuster, or treating provider should sign where required. Ensure the signer has authority and includes printed name, title, and date to validate the action.

What attachments are essential?

Attach relevant medical records, incident reports, and payroll verification when applicable. Missing attachments are a common cause of follow-up requests and processing delays.

How long should I keep copies?

Retain submitted forms through the claim lifecycle and at least three years post-termination; healthcare records tied to the claim should follow HIPAA six-year retention guidance (45 CFR §164.530(j)).

What if the insurer requests corrections?

Respond promptly with corrected fields and a dated cover note. Document correspondence and preserve audit logs to confirm when corrections were made and by whom.

DWC Form 032

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Request for Designated Doctor Examination (DWC Form-032)

Texas Department of Insurance, Division of Workers’ Compensation

Complete, if known:

DWC Claim #

Carrier Claim #

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, Zip Code)

4. Employee County

5. Employee Primary Phone Number

6. Employee Alternate Phone Number

7. Employee Date of Birth

8. Date of Injury

II. EMPLOYER INFORMATION (at the time of injury)

9. Employer Name

10. Employer Phone Number

11. Employer Address (Street or P.O. Box, City, State, Zip Code)

III. INSURANCE CARRIER INFORMATION

12. Insurance Carrier Name

13. Insurance Carrier Address (Street or P.O. Box, City, State, Zip Code)

14. Adjuster Name (First, Middle, Last)

15. Adjuster E-mail Address

16. Adjuster Phone Number

17. Adjuster Fax Number

Only Insurance Carriers Complete Boxes 18 - 22

18. Insurance Carrier’s Authorized Agent Company Name

19. Insurance Carrier’s Bill Review Agent Name

20. Bill Review Agent Address (Street or P.O. Box, City, State, Zip Code)

21. Bill Review Agent Phone Number

22. Bill Review Agent Fax Number

IV. INJURED EMPLOYEE REPRESENTATIVE INFORMATION (if any)

23. Representative’s Name (First, Middle, Last)

24. Representative’s Phone Number

25. Representative’s E-mail Address

26. Representative’s Fax Number

V. TREATING DOCTOR INFORMATION

27. Treating Doctor Name

28. Treating Doctor Phone Number

29. Treating Doctor Address (Street or P.O. Box, City, State, Zip Code)

30. Treating Doctor Fax Number

31. Treating Doctor License Number

32. Treating Doctor License Type

VI. DESIGNATED DOCTOR SELECTION INFORMATION

33. Does the claim involve medical benefits provided through a Certified Workers’ Compensation Health Care Network?

Yes No If yes, provide the name of the network.

34. Does the claim involve medical benefits provided through a political subdivision pursuant to §504.053(b)(2) of the Texas Labor Code?

Yes No

If yes, provide the name of the health care plan.

35. Check all body parts and diagnoses that apply:

Spine and Torso

Upper Extremities

Lower Extremities (excluding feet)

Feet

Teeth and Jaw

Eyes

Other Body Areas or Systems

Traumatic Brain Injury

Spinal Cord Injuries

Severe Burns (including chemical burns)

Multiple Bone Fractures (excluding spinal fractures)

Infectious Diseases (complicated)

Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy)

Chemical Exposure (excluding chemical exposure limited to skin exposure)

Heart or Cardiovascular Condition

Employee’s Name

DWC Claim Number

VII. EXAMINATION / INJURY INFORMATION

36. Provide the specific reason(s) for the requested examination.

37. List all injuries determined to be compensable by TDI-DWC or accepted as compensable by the insurance carrier.

38. Has a previous designated doctor examination been performed for this claim?

Yes No If No, skip boxes 39 - 41.

39. Regarding the most recent designated doctor examination, provide the following information:

a. Name of the designated doctor

b. Date of the examination

40. Provide good cause if this request is within 60 days of a previous designated doctor examination.

41. Explain any change of medical condition since the most recent designated doctor examination.

Employee’s Name

DWC Claim Number

VIII. PURPOSE FOR EXAMINATION

42. Requester: For items A through G below, check the box(es) 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)

Questions for the Designated Doctor to consider in the examination:

B. Impairment Rating (IR)

MMI Date* (required only if Box A is not checked)

Question for the Designated Doctor to consider in the examination:

C. Extent of Injury

Describe the accident or incident that caused the claimed injury.

Question for the Designated Doctor to consider in the examination:

D. Disability – Direct Result

From

To

E. Return to Work

From

To

F. Return to Work (Supplemental Income Benefits)

From

To

Is the qualifying period applicable to the 9th quarter or subsequent quarter?

Yes No

G. Other Similar Issues

IX. REQUESTER CERTIFICATION

43. Check the appropriate box:

Injured Employee Injured Employee Representative Insurance Carrier TDI-DWC

I certify the following:

• I am authorized to request the examination;

• All the information provided on this form is true and correct; and

• I provided a copy of this request to all parties at the time the original request was submitted to TDI-DWC.

I understand that any misstatement, falsification, or omission could cause an incorrect selection of the designated doctor and may result in the TDI-DWC voiding any order issued pursuant to the request or taking enforcement action, including administrative penalties and/or fines.

If “insurance carrier” is checked above, I further certify the following:

I have been authorized by the insurance carrier to provide employees of the company named in Section III, Box 18, with the insurance carrier’s authorization to take all further actions and communicate with the TDI-DWC regarding this DWC Form-032 Request for Designated Doctor Examination.

44. Signature of Requester

45. Printed Name of Requester

46. Date of Signature

Frequently Asked Questions

Request for Designated Doctor Examination (DWC Form-032)

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. The TDI-DWC may also order a designated doctor examination on its own motion.

How often can a designated doctor examination be performed?

Prior to Supplemental Income Benefits (SIBs) eligibility and during the first eight quarters of receiving SIBs, a designated doctor examination may not be performed more than once every 60 days. The TDI-DWC may approve additional requests for an examination within the 60-day period if good cause exists. After eight quarters of SIBs, a designated doctor examination may be performed no more than once per year.

Do I have to complete all the fields on the DWC Form-032?

Failure to provide all required information on the DWC Form-032 may cause a delay in processing and your request may be returned to you.

If the injured employee does not have a treating doctor, you must specify “No Treating Doctor” in the space provided for the treating doctor’s name in Box 27. If any other requested information is not applicable, answer “N/A”.

Where do I file the DWC Form-032?

You are required to provide a copy of the completed DWC Form-032 to all parties at the time you submit the original request to the TDI-DWC. Submit the completed form to TDI-DWC by fax to (512) 804-4121 or by mail to the address shown below.

Texas Department of Insurance

Division of Workers’ Compensation

Designated Doctor Examination Request Processing & Monitoring

7551 Metro Center Drive, Suite 100 • MS-603

Austin, TX 78744-1645

What does TDI-DWC do?

If the request is approved, the TDI-DWC assigns a qualified designated doctor to examine the injured employee. If there is a designated doctor who was previously assigned to the claim, the same doctor will be used as long as the doctor is still qualified and available. If the request is approved, within 10 days the TDI-DWC will issue an order to the parties regarding the examination. If the request is denied, you will receive a notice providing you with the specific reason(s) for the denial.

If you wish to dispute the TDI-DWC’s approval or denial of a Request for Designated Doctor Examination, you are entitled to seek an expedited Contested Case Hearing under 28 Texas Administrative Code §140.3.

Where do I find more information on the designated doctor process?

For more information contact your local TDI-DWC Field Office at 1-800-252-7031. Additional resources that answer common questions about the designated doctor process are also available on the TDI website at http://www.tdi.texas.gov/wc/dd/.

NOTE1: Title 28 Texas Administrative Code §127.1(b)(9) requires that in order to request a designated doctor examination, a request must be submitted on the form prescribed by TDI-DWC. The social security number may be used to identify the injured employee.

NOTE2: 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).

What DWC Form 032 Is and when it applies

DWC Form 032 is a California Division of Workers' Compensation form used within workers' compensation case workflows to capture core claim or case-related details needed by employers, claims administrators, medical providers, and insurers. The form documents identifying information, incident or treatment specifics, administrative notes, and signatures from responsible parties. It is a procedural administrative form rather than a judicial pleading; use and exact processing depend on the local claims administrator or insurer. Electronic handling of the form may be permitted when consistent with state DWC procedures and federal e-signature law.

Why completing DWC Form 032 correctly matters

Accurate completion supports timely claims processing, preserves medical and benefits timelines, and reduces disputes about notice or responsibility. Properly completed forms help claims administrators route documentation, trigger coverage determinations, and maintain an audit trail useful for later review under workers' compensation rules.

Typical users and recipients of DWC Form 032

Lead parties often include employers, claims adjusters, treating medical providers, and the injured worker; each relies on the form for different administrative steps.

Employer representative — completes employer-specific sections and confirms payroll or exposure information.
Claims adjuster — uses the form to record file numbers, coverage decisions, and routing instructions to medical review.
Treating provider — supplies clinical details and treatment dates needed for benefit and authorization decisions.

Keep distribution lists current: an incomplete recipient list is a common cause of processing delays and missed deadlines.

Who may sign or authorize DWC Form 032

Employer Rep

A designated employer representative or human resources officer commonly signs for the employer. That signer should be authorized to provide employment and payroll details and to represent the employer in claims administration; an unauthorized signature can delay verification and reopening steps.

Claims Adjuster

A claims adjuster, claims examiner, or insurer representative can sign when the form records insurer actions. Their signature should include name, title, and date so the file shows who made coverage or routing decisions and when those decisions were recorded.

Key sections to review before you start

Before filling the form, confirm you have the claimant identity, employer and insurer details, incident or treatment dates, specific descriptions, and signature authority. These components determine routing, eligibility checks, and whether additional attachments are required by the claims administrator.

Claimant Info

Full legal name, date of birth, best contact details, and employee ID or SSN last four digits to match the claims file and prevent duplicate records; accuracy avoids processing delays.

Employer Details

Employer legal name, mailing address, industry code, and payroll contact so the claims administrator can verify employment and wage information quickly.

Incident Summary

Date, time, and brief description of injury or exposure; location and activity at the time of injury to support initial medical authorization and investigative steps.

Medical Provider

Treating provider name, clinic address, and dates of service to allow direct contact for records, authorization, or utilization review when necessary.

Insurer/Adjuster

Insurer name, policy number, claim number, and adjuster contact to ensure correct file linkage and to avoid duplicate claim creation.

Signature Block

Printed name, title, signature, and date from the authorized signer; electronic signatures may be accepted when compliant with applicable e-signature law.

Step-by-step: completing DWC Form 032

Follow these steps in order to reduce errors and ensure the document routes correctly within claims administration.

01

Gather records: Collect claimant ID, incident notes, and provider records before opening the form.
02

Enter identifiers: Fill claimant, employer, and claim numbers first to index the form.
03

Describe incident: Provide a concise factual summary of the injury or exposure.
04

Sign and date: Authorized party signs and dates to complete the filing.

Digital workflow settings for eSubmission

Configure your workflow fields and routing to match the claims administrator's intake process when submitting electronically.

Field	Configuration
Index Fields	Require claimant name, date of injury, claim number for upload.
Routing	Auto-route to adjuster email or claims inbox.
Authentication	Enable email or SMS two-factor for signer identity.
Attachments	Allow PDF/X-ray and medical notes uploads.

How electronic submission typically flows

A typical eSubmission sequence ensures traceability and creates the audit record required for later review.

Upload: Sender uploads the completed DWC Form 032 PDF to the claims portal.
Field Mapping: System extracts key fields and populates the claims index.
Signer Authentication: Authorized signer authenticates via email link or MFA.
Audit Trail: Platform captures timestamp, IP, and action history.

Technical and security considerations for eSubmission

Confirm the receiving claims administrator supports electronic upload and accepts e-signed documents under applicable rules.

File Formats: PDF, DOCX accepted by most portals
Authentication: Email link, SMS, or stronger MFA
Encryption: TLS in transit; AES-256 at rest

Attachments and supplementary information commonly required

When you submit DWC Form 032, attach supporting documents that substantiate the entry and reduce follow-up requests from claims administrators.

Medical Records

Include clinical notes, test results, and treatment dates that directly support the reported injury and any recommendations for continued care or work restrictions; clear PDFs reduce follow-up.

Accident Report

Attach an internal incident or safety report with witness statements, photos, or property damage records to document the circumstances surrounding the injury.

Payroll Data

Provide wage or payroll verification when requested to support benefit calculations; include pay period dates and gross wages for continuity.

Authorization Letters

If the provider or employer previously authorized treatment or temporary disability payments, attach copies to speed benefits processing.

Practical tips to avoid delays

Follow these practical controls to reduce processing time and administrative friction when filing DWC Form 032.

Verify identifiers before submission

Cross-check claimant legal name, claim number, and employer details against the claims system to prevent duplicate files and mismatches that trigger manual review.

Use consistent date formats

Enter dates as MM/DD/YYYY throughout the form and any attachments. Inconsistent formats create parsing errors in automated intake systems.

Attach clearly labeled documents

Name PDFs with claimant name, document type, and date. Clear labeling reduces clerical back-and-forth and speeds indexing.

Record the submission

Keep a copy of the submitted packet and capture platform audit logs to resolve future questions about timing or content.

Time-sensitive items and expected response windows

Certain entries or follow-ups tied to DWC forms have practical or regulatory timing expectations; plan for internal deadlines and claim administrator response windows.

Initial reporting:

Report injuries promptly per employer policy; delayed reporting can complicate benefit start dates.

Medical records request:

Allow 7–14 business days for providers to furnish records after release is sent.

Claims acknowledgement:

Adjusters typically acknowledge receipt within 5–10 business days in standard workflows.

Benefits determination:

Coverage or benefit decisions may take several weeks depending on investigation complexity.

Appeal windows:

Meet any appeal or dispute timelines published by the claims administrator or under California workers' compensation rules.

Key processing milestones from submission to resolution

A typical claim-related lifecycle contains discrete stages; plan tasks around these milestones to maintain momentum.

01

Submission

Complete and submit the DWC Form 032 with attachments to the claims portal.

02

Intake Review

Claims administrator validates identifiers and opens the file for investigation.

03

Investigation

Adjuster requests additional records or interviews witnesses as needed.

04

Decision

Claims team issues coverage determination and next-step instructions.

Paper versus electronic handling of DWC Form 032

Compare common attributes of paper and electronic submission paths so you can choose the option that fits your intake and compliance needs.

Criteria	Paper Filing	Electronic Filing
Accepted by DWC
Audit trail	limited	detailed (timestamps, ip)
Processing speed	slower	faster
Preferred for records	physical originals	indexed pdfs

Essential data elements to include

Claimant ID: Full legal name

Date of Incident: MM/DD/YYYY

Employer Info: Legal business name

Claim Number: Insurer claim ID

Provider Details: Clinic name and dates

Authorized Signature: Name, title, date

Consequences of incorrect or late submissions

Processing Delay: Claims may be delayed pending correction

Benefit Interruption: Payments or authorizations can be postponed

Duplicate Records: Incorrect IDs cause duplicate claim creation

Administrative Fines: Potential employer penalties under state rules

Appeal Complexity: Errors complicate later dispute resolution

Privacy Risk: Improper data handling may breach HIPAA

Common mistakes to avoid when preparing DWC Form 032

Using inconsistent claimant names or identifiers across documents, which can produce duplicate files and slow verification.
Entering dates in mixed formats that break automated parsing or cause ambiguity about the onset of treatment or injury.
Failing to attach supporting medical records or payroll information, leading to repeated record requests from the claims administrator.
Allowing unauthorized staff to sign without documented delegation, which can invalidate submissions and require re-signature.

eSignature vendor pricing snapshot for document handling

Compare common pricing and compliance features for electronic signature providers when planning eSubmission of DWC or related forms.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	No	No	Yes, limited	Yes, limited
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Representative use cases for DWC Form 032 in practice

These examples show how organizations use the form in routine claim administration and medical coordination.

Provider Submission

A clinic uploads the completed form with treatment notes to the claims portal

Provider includes treatment dates and diagnosis codes for triage
This reduces phone follow-up and speeds initial authorization for further care, improving continuity for the patient and accelerating claims intake.

Employer Notification

An employer files the form after an on-site incident

Employer attaches internal incident report and payroll verification
Claims adjuster receives all materials in a single packet, enabling a faster coverage decision and reducing back-and-forth about basic facts.

Frequently asked questions about completing DWC Form 032

Answers to common questions about form fields, signatures, electronic submission, and recordkeeping to prevent delays.

Need help? Contact support

Can DWC Form 032 be e-signed?
Yes when the receiving claims administrator or insurer accepts electronic signatures. Electronic signatures are generally enforceable under the ESIGN Act (15 U.S.C. ch. 96, 2000) and UETA when applicable; verify any DWC-specific intake policies before e-signing.
What date format should I use?
Use MM/DD/YYYY for all dates on the form and attachments to ensure consistency with automated intake systems and to avoid ambiguity about incident and treatment timing.
Who must sign the form?
An authorized employer representative, claims adjuster, or treating provider should sign where required. Ensure the signer has authority and includes printed name, title, and date to validate the action.
What attachments are essential?
Attach relevant medical records, incident reports, and payroll verification when applicable. Missing attachments are a common cause of follow-up requests and processing delays.
How long should I keep copies?
Retain submitted forms through the claim lifecycle and at least three years post-termination; healthcare records tied to the claim should follow HIPAA six-year retention guidance (45 CFR §164.530(j)).
What if the insurer requests corrections?
Respond promptly with corrected fields and a dated cover note. Document correspondence and preserve audit logs to confirm when corrections were made and by whom.

Explore Templates

Revocable Living Trust Irrevocable Living Trust Letter Regarding Settlement Documents and Release

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now