Fill and Sign the Texas Intent Form

                                                                                                     (a) your medical condition has improved sufficiently to allow you to return to work without restrictions as of       (b) you reached maximum medical improvement on       (date) with a whole body impairment rating of     (c) you reached maximum medical improvement on       (date) with a whole body impairment rating of       disputing and making a reasonable assessment of                                   I agree with the RME doctor's report I disagree with the RME doctor's report because:                   The carrier waives its right to the remedies provided for under Tex. Labor Code Ann. §408.004(f), and agrees to continue paying temporary The Carrier intends to suspend the payment of TIBs on the I 4th day after the date on which the Commission receives this notice. the employee indicated disagreement with the RIME doctor's opinion on       the treating doctor indicated disagreement with the RIME doctor's opinion on       the carrier filed this notice with the employee and treating doctor on                                                                                           Notice of Intent to Suspend Temporary Income Benefits PART I GENERAL INFORMATION 1. Injured Employee's Name: 2. Telephone #- 3. Mailing Address: 4.(a). Facsimile #- 4(b). Email Address: 5. Date of Injury: 6. TWCC #- 7. Carrier Claim #- 8. Social Security #- 9. Treating Doctor's Name: 1 0. Telephone #- 11.. Mailing Address: 12. Facsimile #- 13. Email Address: PART II GROUNDS FOR SUSPENSION 1 4. Entitlement to temporary income benefits (TIBs) is based upon the existence of disability. Attached is a copy of a report from Doctor (RME doctor) which you should have received previously, that indicates that you are no longer entitled to TIBs because: (date). % which the carrier hasaccepted. % which the carrier is %. PART III EMPLOYEE/TREATING DOCTOR RESPONSE As required by Rule 126.7, this notice is being provided to you in an attempt to ensure that you and your treating doctor have the opportunity to respond tothis opinion and to let you know that if you disagree with this determination, this notice will be filed with the Commission to request a benefit reviewconference (BRC) to resolve this issue. Rule 126.7 requires a treating doctor to respond within seven days from the date of this notice and you arerequested to respond by this date as well. Response should be sent to: 1 5. Name of Carrier 1 6. Name of Adjuster 1 7. Toll Free Number 18. Facsimile Number 19. Email Address 20a . 20b. 21. Signature Date 22. Telephone Number PART IV CARRIER NOTICE TO THE COMMISSION 23. (a) income benefits pending receipt of the designated doctor's report. The Commission will schedule a designated doctor's examination to be performed no later than 3 weeks from the date on which the commission receives this form. The carrier may suspend temporary income benefits if an employee fails to attend a designated doctor examination without good cause, pursuant to Rule 126.6(h). 23 (b) Upon concurrence by the claimant, the carrier agrees to continue paying impairment income benefits, based on the carrier doctor'simpairment rating, pending receipt of the designated doctor's report. The Commission will schedule a designated doctor's examination to be performed no later than 3 weeks from the date on which the commission receives this form. 23 (c) Carrier is permitted to file this notice with the Commission under rule I 26.7(e) because the carrier is currently paying TIBs and: (date) and the treating doctor has not indicated agreement with the RIME doctor's opinion. (date). (date filed) yet more than seven days have passed neither has responded. 24. (a) Weekly TIBs Rate: (b.) Weekly I I Bs Rate: 25. a. Name of BRC Contact Person: b. Direct Telephone #- c. Facsimile #- d. Email Address: 26. Printed Name of Person Filing Notice: 27. Signature: Date: PART V TRANSMISSION TRACKING INFORMATION To Employee To Treating Doctor To Commission Date Transmitted Number of Pages TWCC 34 (Rev. 09/00) Rule 126.7 TEXAS WORKERS' COMPENSATION COMMISSION INSTRUCTIONS FOR NOTICE OF INTENT TO SUSPEND TEMPORARY INCOME BENEFITS This form is the Notice of Intent provided by TWCC Rule 126.7 (relating to Suspension of Temporary Income Benefits Based upon the Opinion of a Carrier-Selected Required Medical Examination Doctor). This notice is only to be used for when the carrier-selected RME doctor certifies that the employee has reached MMI or can safely return to work without restrictions. An RME doctor's release to return to work with restrictions is governed by 129.6 (relating to Bona Fide Offers of Employment). Filing Requirements This notice shall be filed in accordance with Rule 126.7. Carriers electing to pursue for the suspension of temporary income benefits based upon receipt of a report by the carrier's RME doctor which indicates that the employee is able to safely return to work without restriction or that the employee has reached MMI, the carrier shall file this notice along with a copy of the RME doctor's report with the treating doctor and the employee to attempt to obtain their agreement or disagreement with the RME doctor's opinion. As provided in 126.7(e), the carrier shall not file the notice with the Commission until the earlier of: 1) 2) The carrier receiving the disagreement of the treating doctor or the employee; or The eighth day after the date the carrier filed the notice with the treating doctor and employee. The carrier is not to file this notice with the Commission if: 1) the carrier has already suspended payment of TIBs prior to receipt of the RME doctor's opinion (i.e. because the employee had already returned to work without lost wages); or 2) the treating doctor indicates agreement with the RME doctor's opinion about MMI or return to work without restrictions which allows the carrier to suspend TIBs immediately based upon the treating doctor's opinion. Information Requirements PART I CARRIER - Complete information required by Form. PART 11 CARRIER - Check the box next to the appropriate RME doctor's opinion and provide required information. PART III CARRIER - Fill in all required blank fields identifying the person/means to contact the carrier regarding the notice. TREATING DOCTOR and EMPLOYEE - Indicate agreement or disagreement with RME doctor's opinion. If disagreeing, provide reason for disagreement. PART IV CARRIER - 23 (a) and (b) - Check the appropriate box if carrier agrees to continue payment of TIBs or IlBs. Note - The Commission will not schedule a BRC under Sections 23(a) or (b) unless the designated doctor's appointment cannot be held within 3 weeks from receipt of this form by the Commission. 23(c) - Check box(es) which indicates why carrier is permitted to file Notice with the Commission and provide required information relating to the employee's benefit status. NOTE - Wage information is confidential. Carrier shall not include this information on the copy of the notice sent to the treating doctor. PART V CARRIER - Complete information. This section was provided in part to eliminate the need for a separate facsimile cover page because the PART I has name/number information and this part has the date sent and number of pages included. When filing this notice with the Commission, the carrier shall include a copy of the RME doctor's report and shall include copies of the treating doctor's and employee's responses, if any. In order to reduce paper, if either the treating doctor or employee responded in writing using the notice, the carrier may complete PART IV of the copy of the notice which contains their response and file that notice with the Commission. Twcc 34 (Rev. 09/00) Rule 126.7 TEXAS WORKERS' COMPENSATION COMMISSION