Texas Form Dwc049 is a vital document for every individual residing in the state of Texas. The form is used to declare any and all assets that are held by the individual. It is important to understand the importance of this document and how it can be utilized to protect your assets. Failure to complete and submit this form could result in significant penalties. Contact our office today for more information on Texas Form Dwc049.
This knowledge will aid you to grasp better the details of the texas form dwc049 before starting filling it out.
| Question | Answer |
|---|---|
| Form Name | Texas Form Dwc049 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | MCCH, TX, DWC, responder |
Texas Department of Insurance
Division of Workers’ Compensation
7551 Metro Center Drive, Suite 100 •
(512)
DWC049
Complete if known:
DWC Claim #
Carrier Claim #
Request to Schedule a Medical Contested Case Hearing (MCCH)
Type (or print in black ink) each item on this form
I. REQUEST SPECIFICATIONS
1. Check the appropriate box to indicate the type of medical contested case hearing you are requesting:
Appeal of an Independent Review Organization (IRO) Medical Necessity Decision to the
Appeal of Medical Fee Dispute Decision to State Office of Administrative Hearings (SOAH). Enter the date the Benefit Review Conference ended (mm/dd/yyyy)
IMPORTANT NOTE: In an appeal to SOAH, the
2. Check the appropriate box(es) for services you are requesting, if any:
Expedited MCCH (specify reason*)
Special Accommodations (specify)
*Does not include claim involving a first responder. See Section III, Box 11 regarding expedited first responder claims.
II.INJURED EMPLOYEE CLAIM INFORMATION
3.Employee’s Name (Last, First, Middle)
4.Employee’s Physical Address (Street, City, State, Zip Code)
5. Employee’s Social Security Number*
6. Date of Injury (mm/dd/yyyy)
7.Insurance Carrier’s Name
8.Employer’s Business Name (at the time of the injury)
9.Employer’s Business Address (Street or PO Box, City, State, Zip Code)
*Title 28 Texas Administrative Code §133.307 and §133.308 require that in order to process a request for medical dispute resolution, a request must be filed in the form and manner required by
For
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DWC049
III.REQUESTER INFORMATION
10.Check the appropriate box:
Injured Employee
Insurance Carrier
Health Care Provider
Attorney for__________
Subclaimant
Pharmacy Processing Agent
11. Provide the following information:
Is the injured employee a first responder, as defined in Texas Labor Code §504.055, who sustained a serious bodily
injury*? |
Yes |
No |
If yes,
•Medical Fee Dispute: MCCH will be expedited only if the requester is the injured employee.
•Medical Necessity Dispute: MCCH will be expedited regardless of requester type.
*bodily injury that creates a substantial risk of death or that causes death, serious permanent disfigurement, or protracted loss or impairment of the function of any bodily member or organ
12. If injured employee is checked in Box 10, is the employee assisted by the Office of Injured Employee
Counsel (OIEC)? |
Yes |
No |
13.Requester's Mailing Address (Street or PO Box, City, State, Zip Code)
14. Requester’s Printed Name/Title
15. Phone Number
16. Requester’s Signature
17. Date of Signature (mm/dd/yyyy)
NOTE: With few exceptions, upon your request, you are entitled to be informed about information
Employee’s Name:
DWC Claim Number:
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DWC049
Frequently Asked Questions
Request to Schedule Medical Contested Case Hearing (MCCH)
Where will the MCCH be held?
•Medical Fee Dispute: The State Office of Administrative Hearings (SOAH) will schedule the hearing at the SOAH offices in Travis County.
•Medical Necessity Dispute: The Texas Department of Insurance, Division of Workers’ Compensation
What type of special accommodations will be provided?
The
Who determines whether an MCCH is expedited?
If an expedited MCCH is requested in Section I, Box 2, the
If Yes is checked in Section III, Box 11 to indicate that the injured employee is a first responder, the TDI- DWC will expedite an MCCH as follows:
•Medical Fee Dispute: MCCH will be expedited only if the requester is the injured employee.
•Medical Necessity Dispute: MCCH will be expedited regardless of requester type.
What is the deadline for filing the DWC
•Medical Fee Dispute: You must submit the form to the
•Medical Necessity Dispute: You must submit the form to the
Where do I send the DWC
The completed form, including a copy of the IRO decision (if applicable), must be faxed to (512)
Texas Department of Insurance
Division of Workers’ Compensation
7551 Metro Center Drive, Suite 100 •
Austin, TX
Is any of the requested information optional?
No, provide all requested information. An MCCH will only be scheduled if the form is complete. An incomplete form may delay resolution of your dispute.
Am I required to attend the MCCH?
If you do not attend, the MCCH may be held without you. Failure to attend an MCCH could result in a recommendation of a penalty or fine unless you can show 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.
Who do I contact if I have questions about requesting an MCCH?
Contact the
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