Fill and Sign the For Use Only by Employees Not in Workers Compensation Health Care Networks or Certain Political Subdivision Health Care Plans Form

DWC053฀ DWC053฀Rev.฀03/12 ฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀ Page฀1฀of฀ 2฀ ฀ Texas฀Department฀o f฀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 H ealth 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) ฀ ฀ ฀ ฀ ฀ ฀ ฀ 2.฀Employee’s฀Social฀Security฀Number ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ 3.฀Employee’s฀ Mailing฀Address฀ (Street฀or฀PO฀Box,฀City ,฀State ,฀Zip ฀Code )฀ ฀ ฀ ฀ ฀ ฀ ฀ 4.฀Employee’s฀Telephone฀Number ฀ (฀ ฀ ฀ ฀ ฀ )฀฀ ฀ ฀ ฀ ฀ ฀ 5.฀Alternate฀Telephone฀Number฀ (if฀available)฀ (฀ ฀ ฀ ฀ ฀ )฀฀ ฀ ฀ ฀ ฀ ฀ 6.฀Date฀of฀Injury฀ (mm/dd/yyyy)฀฀ ฀ ฀ ฀ ฀ ฀ ฀ 7.฀Attorney/Representative’s฀Name ฀ (if฀applicable)฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀฀ 8.฀Attorney/Representative’s฀Address฀ (Street฀or฀PO฀Box,฀City,฀State,฀Zip฀ Code )฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ 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฀฀ ฀ ฀ ฀ ฀ ฀ 12.฀Insurance฀Carrier's฀Address฀ (Street฀or฀PO฀Box,฀City,฀State,฀Zip ฀Code )฀ ฀ ฀ ฀ ฀ ฀ ฀ 13.฀Adjuster’s฀Name ฀฀ ฀ ฀ ฀ ฀฀ 14.฀Adjuster’s฀Telephone฀Number฀ ฀(฀ ฀ ฀ ฀ ฀)฀฀ ฀ ฀ ฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀ ฀ ฀ ฀ext.฀ ฀ ฀ ฀ ฀ ฀ ฀ 15.฀Adjuster’s฀Fax฀Number ฀(฀ ฀ ฀ ฀ ฀)฀฀ ฀ ฀ ฀ ฀ ฀ ฀ IV.฀TREATING฀DOCTOR ฀INFORMATION ฀ Current฀Treating฀Doctor ฀ 16.฀Current฀ Treating฀ Doctor's฀N ame฀(First,฀Middle,฀Last)฀ and฀Title฀(MD,฀DO,฀DC,฀etc.) ฀฀ ฀฀ ฀ ฀ ฀ ฀ ฀ 17 .฀Current฀Treating฀Doctor’s฀ Telephone฀Number ฀ (฀ ฀ ฀ ฀ ฀ )฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀ ฀ ฀ ฀ ฀ ฀ext.฀฀ ฀ ฀ ฀ ฀ ฀ 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 ฀ (฀ ฀ ฀ ฀ ฀ )฀฀ ฀ ฀ ฀ ฀ ฀ 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฀N ame฀(First,฀Middle,฀Last)฀ and฀Title฀(MD,฀DO,฀DC,฀etc.) ฀฀ ฀฀ ฀ ฀ ฀ ฀ ฀ 23 .฀Requested฀ Treating฀Doctor's฀Telephone ฀Number ฀฀ (฀ ฀ ฀ ฀ ฀ )฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀ ฀ ฀ ฀ ฀ ฀ext.฀฀ ฀ ฀ ฀ ฀ ฀ 24.฀Requested฀ Treating฀Doctor’s฀License฀Number ฀ ฀฀ ฀ ฀ ฀ ฀ ฀ 25 .฀Requested฀ Treating฀Doctor’s฀Fax฀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) ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ 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.฀ For฀TDI -DWC฀Use฀Only ฀ 29.฀Employee's฀Signature ฀(r equired) ฀ ฀ 30 .฀Date ฀ ฀ ฀ ฀ ฀ ฀ ฀ NOTE :฀ ฀With฀ few฀ exceptions,฀ upon฀ your฀ request,฀ you฀ are฀ entitled฀ to฀ be฀inf ormed฀ 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฀ DWC053฀Rev.฀03/12 ฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀ Page฀2฀of฀ 2฀ Frequently฀Asked฀Questions ฀ Employee฀Request฀to฀Change฀Treating฀Docto r฀(DWC฀Form -053) ฀ For use ONLY by Employees NOT in Workers’ Compensation Health Care Networks or Cer tain Political Subdivision Health Care Plans฀฀ ฀ Who฀may฀use฀this฀form฀to฀change฀treating฀doctor s?฀ Only฀ an฀ injured฀ employee ฀(a)฀ who฀ is฀ covered฀ by฀ the฀ Tex as฀workers’฀ compensation฀ system; ฀(b) ฀who฀ has฀ a฀c laim฀ with฀ a฀dat e฀ 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฀ contrac ting฀ 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 ( TDI- DWC )฀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 :฀ • ฀ y ou฀believe฀treatment ฀provided฀by ฀your ฀current฀treating฀doctor฀is฀ medically฀inappropriate; ฀ • ฀ y ou฀believe฀you฀are฀not฀receiving฀appropriate฀medical฀care฀to฀reach฀maximum฀m edical฀improvement;฀ • ฀ y ou฀are฀concerned฀about฀the฀professional฀reputation฀of฀your฀current฀treating฀docto r;฀ • ฀ t here฀is฀a฀conflict฀between฀you฀and฀your฀current฀treating฀doctor฀to฀the฀extent฀that฀ the฀doctor-patient฀relation ship฀is฀ jeopardized฀or฀impaired;฀or ฀ • ฀ y our฀ 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฀ yo ur฀ 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 TDI - DWC 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฀ • ฀ y our฀ 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฀d octor’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,฀ y ou฀must ฀ have฀ the฀ doctor฀ sign฀ the฀ DWC฀ Form -053฀ in฀ Box฀ 27.฀The฀ treating฀ doctor฀ must฀ be฀ a฀ doctor฀ as฀ defined฀ in฀ the฀ Texas฀ Labor฀ Code ฀ § 401.011.฀A ฀non -physician฀ practitioner,฀e.g.฀a฀nurse฀practitioner฀or฀a฀physician’s฀assistant,฀cannot ฀be฀a฀treating฀doctor.฀ ฀ Where฀do฀I฀file฀the฀ DWC฀Form-053 ?฀ You฀can฀submit฀the฀form ฀and฀any฀supporting฀documentation฀to฀the฀ TDI-DW C by: ฀ • ฀ fax฀ to฀(512)฀804 -4378;฀or ฀ • ฀ mail฀to฀the฀Texas฀Department฀of฀Insurance,฀Division฀of฀Workers’฀Compens ation,฀7551฀Metro฀Center฀Drive,฀Suite฀100,฀ MS -94, ฀Austin,฀Texas฀78744 -1645. ฀ ฀ What฀does฀ the฀TDI-DWC฀do? ฀ Within฀10฀days฀of฀receiving฀the฀signed฀DWC฀Form -053,฀the฀ TDI-DWC฀will฀review฀and฀process฀the฀request. ฀ • ฀ If฀ the฀ request฀ is฀ approved,฀ the฀TDI-DWC฀ will฀ issue฀ an฀ approval฀ order฀ and฀ send฀ a฀ copy฀ to฀ the฀ injured฀ employee, ฀ injured฀ employee’s฀ representative฀ (if฀ any),฀ insurance฀ carrier,฀ prior฀ tr eating฀ doctor฀ and฀ newly฀ approved฀treating฀ doctor. ฀ • ฀ If฀ the฀ request฀ is฀ denied,฀ the฀TDI-DWC฀ will฀ issue฀ a฀ denial฀ order฀ and฀ send฀ a฀c opy฀ to฀ the฀ injured฀ employee,฀ injured฀ employee’s฀representative฀(if฀any),฀insurance฀carrier฀and฀requested฀treatin g฀doctor.฀ ฀ NOTE: ฀If you do not agree with the TDI-DWC’s decision, you must dispute the decision within 10 days of receiving the order. Cont act the TDI- DWC field office ha ndling the claim at 1 -800 -252 -70 31 for more information about the dispute process . The insurance carrier also has the right to dispute the decision.