Dwc053 Form PDF Details

Design of a Wassermann-equivalent (Dwc053) form is outlined. The objective of the Dwc053 form is to improve patient care by reducing errors associated with handwritten forms and improve communication between patients and health professionals. By using an electronic form, patients can provide accurate information, which health professionals can quickly access and act upon. clinical research shows that use of electronic forms can lead to improved patient safety, satisfaction, adherence to care plans, and quality of care. Dwc053 will be available in both English and Spanish versions.

QuestionAnswer
Form NameDwc053 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namestexas treating doctor, dwc 53, Ste, DWC-053

Form Preview Example

Texas฀Department฀of฀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฀

DWC053฀

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 Health 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฀฀

 

15.฀Adjuster’s฀Fax฀Number฀

 

฀ ฀ ฀ ฀ ฀

(฀ ฀ ฀ ฀ ฀ )฀฀ ฀ ฀ ฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀ ฀ ฀ext.฀฀ ฀ ฀ ฀ ฀

 

(฀ ฀ ฀ ฀ ฀ )฀฀ ฀ ฀ ฀ ฀

 

 

 

 

 

 

IV.฀TREATING฀DOCTOR฀INFORMATION฀

 

 

 

 

 

 

Current฀Treating฀Doctor฀

 

 

 

 

16.฀Current฀Treating฀Doctor's฀Name(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฀Name(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.

29.฀Employee's฀Signature(required)฀

30.฀Date฀

฀ ฀ ฀ ฀ ฀

For฀TDI-DWC฀Use฀Only฀

NOTE:฀฀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).฀

DWC053฀Rev.฀03/12฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀Page฀1฀of฀2฀

DWC053฀

Frequently฀Asked฀Questions฀

Employee฀Request฀to฀Change฀Treating฀Doctor฀(DWC฀Form-053)

For use ONLY by Employees NOT in Workers’ Compensation Health Care Networks or Certain Political Subdivision Health Care Plans

Who฀may฀use฀this฀form฀to฀change฀treating฀doctors?฀

Only฀an฀injured฀employee฀(a)฀who฀is฀covered฀by฀the฀Texas฀workers’฀compensation฀system;฀(b)฀who฀has฀a฀claim฀with฀a฀date฀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฀contracting฀ 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:฀

฀ you฀believe฀treatment฀provided฀by฀your฀current฀treating฀doctor฀is฀medically฀inappropriate;฀

฀ you฀believe฀you฀are฀not฀receiving฀appropriate฀medical฀care฀to฀reach฀maximum฀medical฀improvement;฀

฀ you฀are฀concerned฀about฀the฀professional฀reputation฀of฀your฀current฀treating฀doctor;฀

there฀is฀a฀conflict฀between฀you฀and฀your฀current฀treating฀doctor฀to฀the฀extent฀that฀the฀doctor-patient฀relationship฀is฀ jeopardized฀or฀impaired;฀or฀

฀ your฀ 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฀ your฀ medical฀ bills.฀ Provide฀ documentation฀from฀your฀current฀treating฀doctor,฀if฀available.฀

You฀may฀notrequest฀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฀

฀ your฀ 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฀doctor’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,฀ you฀musthave฀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-DWC by:฀

fax฀to฀(512)฀804-4378;฀or฀

฀ mail฀to฀the฀Texas฀Department฀of฀Insurance,฀Division฀of฀Workers’฀Compensation,฀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฀ treating฀ doctor฀ and฀ newly฀ approved฀ treating฀ doctor.฀

If฀the฀request฀is฀denied,฀the฀TDI-DWC฀will฀issue฀a฀denial฀order฀and฀send฀a฀copy฀to฀the฀injured฀employee,฀injured฀ employee’s฀representative฀(if฀any),฀insurance฀carrier฀and฀requested฀treating฀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. Contact the TDI- DWC field office handling the claim at 1-800-252-7031 for more information about the dispute process. The insurance carrier also has the right to dispute the decision.

DWC053฀Rev.฀03/12฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀Page฀2฀of฀2฀

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Step no. 1 for filling out dwc53

2. Once your current task is complete, take the next step – fill out all of these fields - CurrentTreatingDoctor, CurrentTreatingDoctorsFaxNumber, RequestedTreatingDoctor, Datemmddyyyy, By signing this formI confirmthat, and ForTDIDWCUseOnly with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Part no. 2 for filling out dwc53

Those who work with this form frequently make some errors when completing CurrentTreatingDoctor in this part. Remember to re-examine what you enter here.

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How you can complete dwc53 portion 3

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