Fill and Sign the Tx Workers Compensation Form

TWCC No:      Carrier Claim No:       TO:             has received a report from Dr.             has received a report from Dr.       assigned a whole body impairment rating of       additional payments of temporary income benefits. You will receive       income benefits at the rate of $       will end approximately             reasonable assessment of       benefits for                         INSURANCE CARRIER'S ADDRESS:       NOTIFICATION REGARDING MAXIMUM MEDICAL IMPROVEMENT AND/OR IMPAIRMENT RATING Entitlement to impairment income benefits begins the day after the date you have been certified as having reached maximum medical improvement. Benefits are payable at 70% of your average weekly wage, not to exceed the state average weekly wage, and are paid for a period of three weeks for each percentage point of impairment. (copy attached) stating that you have reached maximum medical improvement and have been assigned a whole body impairment rating of 0%. Based on this report, you are not eligible for additional income payments of any type. Enclosed is your final payment of temporary income benefits. You continue to remain entitled to receive medical treatment related to your injury. To dispute this finding, contact the TWCC field office handling your claim or call 1-800-252- 7031. (copy attached) stating that you have reached maximum medical improvement and have been %. Based on this report, you will not receive weeks of impairment unless you or the insurance carrier dispute the impairment rating. Enclosed is your first payment of impairment income benefits. These benefits You continue to remain entitled to receive medical treatment related to your injury. To dispute this finding, contact the TWCC field office handling your claim or call 1-800-252-7031. is disputing the doctor's impairment rating and has made a % impairment. Enclosed is your first payment of impairment income benefits. Based on the carrier's assessment, the carrier will pay impairment income weeks pending resolution of the impairment rating dispute. IF YOU DO NOT AGREE WITH THE FINDING OF MAXIMUM MEDICAL IMPROVEMENT OR WITH THE PERCENTAGE OF IMPAIRMENT ASSIGNED BY THE DOCTOR, YOU MAY DISPUTE THE RATING BY CONTACTING THE TEXAS WORKERS' COMPENSATION COMMISSION WITHIN 90 DAYS FROM RECEIVING NOTICE OF THE DOCTOR'S RATING. FOR ASSISTANCE, CONTACT THE COMMISSION FIELD OFFICE HANDLING YOUR CLAIM OR CALL 1-800-252-7031. FROM: ADJUSTER'S NAME: ADJUSTER'S PHONE NO: INSURANCE CARRIER'S NAME: TWCC-28 (8-94) TEXAS WORKERS' COMPENSATION COMMISSION