Fill and Sign the Dwc Form 045 Request to Schedule Reschedule or Cancel

DWC045 DWC045 Rev. 07/17 Page 1 of 4 Send completed form to TDI-DWC field office handling the claim R equest to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC) , or to Proceed Directly to Contested Case Hearing (CCH) Type ( or print in black ink ) each item on this form I. REQUEST SPECIFICATIONS 1. Check ONLY one box to indicate the purpose of your request: Schedule BRC Reschedule BRC Cancel BRC Proceed directly to CCH 2. Check applicable box(es) for services you are requesting: Special Accommodations (Please specify) Expedited BRC (Provide reason ) ____________________________________________ ____________________________________________ II. INJURED EMPLOYEE CLAIM INFORMATION 3. Employee's Name (Last, First, Middle ) 4. Employee's Physical Address 5. Insurance Carrier's Name 6. Date of Injury (mm-dd -yyyy) 7. Social Security Number (last 4 digits) XXX -XX- 8. Employer's Business Name (at the time of the injury) 9. Employer's Business Address III. PARTY REQUESTING TO SCHEDULE, RESCHEDULE OR CANCEL A BRC , OR TO PROCEED DIRECTLY TO CCH 10 . Check the appropriate box: Injured Employee Insurance Carrier Employer Sub- claimant Beneficiary Attorney for 11. Is the injured employee assisted by the Office of the Injured Employee Counsel (OI EC)? Yes No 12. Requester’s Typed or Printed Name 13. Requester's Mailing Address (Street or PO Box, City State Zip) 14 . Business/Firm Name (if applicable) 15. Phone Number 16. Alternate Phone Number Request to SCHEDULE a BRC (Complete Sections IV and V) or CCH (Complete Sections IV and VI ) IV. ISSUE (S) FOR BRC OR CCH 17 . Check applicable box(es) to identify the disputed issue(s) : Compensability of the claim* Extent of the compensable injury Entitlement to temporary income benefits Entitlement to supplemental income benefits Average weekly wage determination Designated doctor’s certification of maximum medical improvement Designated doctor’s assessment of whole body impairment rating Entitlement to death benefits and/or burial benefits Failure of carrier or employer to provide employee required network information Othe r *An employer may check this box only if the insurance carrier has accepted liability. 18. Briefly describe each disputed issue (additional pages may be attached, if necessary). For TDI-DWC Use Only Complete if known: DWC Claim # Carrier Claim # DWC045 DWC045 Rev. 07/17 Page 2 of 4 V . DOCUMENTATION OF YOUR EFFORTS TO RESOLVE THE ISSUE(S) 19. Provide the date the opposing party was notified of the dispu ted issues (mm -dd -yyyy): 20 . Attach the following to this form : • a description of all efforts you have made to resolve the disputed issue(s) • supporting documentation NOTE : If this information is not provided, a BRC may not be scheduled . 21 . I certify that prior to this request I have made reasonable efforts to resolve the disputed issue(s) identi fied in Section IV above and that any pertinent information in my possession ha s been provided to the opposing party or parties. I certify that all the information provided on this form is true and correc t. I certify that I will provide a copy of this request to the opposing party or parties. Signature of Requester_______________________________________________________Date______________________ VI. PROCEED DIRECTLY TO CCH 22. If requesting to proceed directly to CCH, does the opposing party agree with this request? Yes No 23 . Texas Department of Insurance, Division of Workers’ Compen sation (TDI-DWC) rules allow parties to proceed directly to a CCH if the TDI-DWC determines that mediation would not prove effective to resolve the dispute; necessary ev idence cannot be obtained without a subpoena; or the situation of the parties or the nature of the facts or law of the case is such that the overal l policy of the Workers’ Compensation Act would be advanced by proceeding directly to a CCH. (28 Tex. Admin. Code § 142.5(b) ). P lease p rovide information regarding why your dispute should proceed d irectly to CCH, including whether you have exchanged per tinent information with the opposing party or parties and any ef forts you may have made to resolve the disputed issues . 24. I certify that I will provide a copy of this request to the opp osing party or parties. Signature of Requestor ___________________________________________________ Date ________________________________ DWC045 DWC045 Rev. 07/17 Page 3 of 4 Request to RESCHEDULE or CANCEL a B RC (Complete Section V II) VII . DOCUMENTATION OF GOOD CAUSE FOR RESCHEDULING OR CANCELING A BRC 25. Check ONE box below to indicate the description applicable to your request : Cancel PRIO R to BRC (Complete 2 6 and 2 9) Resc hedule PRIOR to BRC (Complet e 26, 2 8, and 2 9) Reschedule AFTER failing to attend BRC (Complete 2 7, 2 8, and 2 9) 26. If you are requesting to reschedule or cancel a BRC and the da te you are submitting this form is more than 10 days after the date* you received the notice of setting but before the BRC is scheduled to be held , attach the indicated information and any supporting documentation to this form: a) a description of objective facts beyond your control, which reasonably:  prevent you from attending the BRC; or  prevent the BRC from accomplishing its purpose (This may include a description of your need for a reasonable amount of additional time to secure necessary evidence for the di spute); OR b) a description of objective facts which make the BRC unnecessary. * The date the notice of setting is received is deemed to be the 5 th day after the date of the notice. NOTE: If this information is not provided, the BRC may not be rescheduled or canceled . Canceling a BRC without simultaneously rescheduling is considered a withdrawal of the dispute on the issue and must comply with TDI -DWC rule 130.12, if applicable . If you did not submit the initial request for the BRC that you are requesting to reschedule or cancel, have you obtained the agreement of the opposing party to the rescheduling or cancelation of the BRC ? Yes No 27. If you are requesting to reschedule after failing to attend a BRC, you must attach a description of objective facts beyond your control, which reasonably prevented you from attending the BRC and from notifying TDI -DWC to cancel or reschedule in advance of the BRC; If you do not submit the request by close of business on the third business day after the BRC was held , you must also attach a description of objective facts beyond your control, which reasonably prevented you from doing s o and which justify the subsequent delay in filing the request. Attach any supporting documentation. NOTE: If this information is not provided , the BRC may not be re scheduled. 28. Check the appropriate box below: The information provided in the initial request for this BRC has not changed. Information provided in the initial request for this BRC has changed. (If this box is checked, you must complete Sections IV and V of this form. ) For TDI-DWC Use Only 29. I certify that I will provide a copy of this request to the opposing party or partie s. Signature of Requester__________________________________________________Date______________ NOTE: With few exceptions, upon your request, you are entitled to be informed about t he 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 (Gov ernment Code, §559.004). DWC045 DWC045 Rev. 07/17 Page 4 of 4 Frequently Asked Questions Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC) , or to Proceed Directly to Contested Case Hearing (CCH) NOTE: This form may only be used to request the scheduling, rescheduling, or cancelation of a BRC, or to proceed directly to a C CH. Do not submit this form to schedule a BRC unless you are prepared to proceed. This form should not be used to request other actions by the TDI-DWC, such as a letter of clarification . Where will the BRC or CCH be held? The Texas Department of Insurance, Division of Workers’ Compensation (TDI -DWC) will schedule the BRC or CCH at a location not more than 75 miles from the injured employee’s residence at the time of the injury or address on this form, unless good cause exists for the selection of a different loc ation. You may request another location, but must provide an acceptable re ason to relocate the proceeding. The TDI-DW C will determine whether a change in location is appropriate. In addition, injured employees may request the BRC be held through a telephone conference. What type of special accommodations will TDI -DWC provide? The TDI-DWC will provide accommodations to parties who qualify under the Americans with Disabilities Act (ADA), and other reasonable accommodations at the discretion of the presiding officer. Who determines whether a BRC is expedited? If an expedited BRC is requested, the TDI -DWC will determine whether scheduling the BRC more quickly is appropriate. For example, an expedited BRC may be granted in the foll owing circumstances: • no income benefits have been paid because of the issue in dispute; or • the issue in dispute is an official action taken by the TDI-DWC . How do I document my efforts to resolve the disputed issues before requesting a BRC? Attach copies of correspondence, e - mails, facsimiles, records of telephone contacts, summaries of meetings, or telephone conversations. What is pertinent information documentation? It is documentation that is related to the disputed issue and will be used at the BRC to help resolve the dispute. Examples of pertinent information are: medical records, requests for a designated doctor exam; letters of clarification to a designated doctor; required medical examination repor ts; or a treating doctor’s response to a designated doctor report. You are required to provide pertinent information to the opposing party before requesting a BRC. You are also r equired to provide pertinent information to the TDI-DW C not later than 14 days before the scheduled BRC, but you should not attach this information to this request. Who determines whether to reschedule or cancel a BRC? The determination of whether there is good cause to reschedule or cancel a BRC is made at the discretion of the TDI-DW C benefit review officer on a case -by -case basis. Even if good cause exists, the b enefit review officer may deny the request based on other considerations. Where do I send the form? You can fax, mail, or personally deliver the completed form to the field office handling the claim . For field office addresses, call the TDI -DW C at 1 -800 -252 -7031 or visit the agency’s webs ite at http://www.tdi.texas.gov//wc/dwccontacts.html . Failure to file the form with the appropriate field office may delay the processing of your request. You are also required to send a copy to the opposing party or parties. Am I required to attend the BRC or CCH Failure to attend a BRC or CCH could result in a recommendation of a penalty or fine unless you can sho w good cause for your absence. An injured employee should attend any proceeding related to a dispute about his or her claim, even if the injured employee did not request the proceeding. Does the filing of this form meet the requirement s for disputing the certification of MMI/IR? The filing of this form constitutes a dispute for purposes of Texas Labor Code §408.123(e) only if the TDI-DWC determines that the form is complete in accordance with TDI -DW C rules and a proceeding is scheduled. In such cases, the disput e will be considered effective the date the party filed the request . Canceling a BRC without simultaneously rescheduling is considered a withdrawal of the dispute on the issue and must comply with TDI -DW C rule 130.12 . Who do I contact if I have q uestions? C ontact the TDI-DWC by calling 1-800 -252 -7031. An injured employee who is not represented by an attorney may also receive assistance by contacting the Office of Injured Employee Counsel (OIEC) at 1 -866 -393 - 6432. What happens after the TDI-DWC receives my DWC Form -045 ? If your request to schedule, reschedule, or cancel a BRC is approved , you and the opposing party or parties will be notified , including the time, date and location of the BRC , if applicable . If you are notified your request to schedule a BRC is denied because the request is incomplete , you may resubmit the request with additional information or request an expedited CCH to determine if your request should be approved. If your request to proceed directly to CCH is granted, the TDI - DWC will set a CCH and you and the opposing party or parties will be notified. If your request to proceed directl y to CCH is denied, the TDI -DWC will notify you and the opposing party or parties and may set a BRC.