Dwc Form-153 Request For Copies Of Confidential Claimant Information

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SUBMIT A SEPARATE
TEXAS DEPARTMENT OF INSURANCE
DWC FORM-153
DIVISION OF WORKERS' COMPENSATION
FOR EACH DWC OR IAB #
7551 Metro Center Drive, Suite 100
Austin, TX 78744
REQUEST FOR COPIES OF
CONFIDENTIAL CLAIMANT INFORMATION
Please carefully read the information on both sides of this form and the accompanying Instructions. INCORRECTLY COMPLETED
FORMS WILL BE RETURNED TO REQUESTOR WITHOUT ACTION. This form must be signed by a party eligible to receive the
information requested. Additional documentation may be required for eligibility. The signature must be notarized.
(Please type or print)
Provide the following information to identify the requested claim file.
I. CLAIM FILE IDENTIFICATION.
DWC or
Employee's Social
X X
X X X
IAB Number
Security Number (last 4)
--
--
Employee’s Name
Employee's Date of Injury
--
--
Last
First
MI
m
m
d
d
y
y
y
y
Address
City
State
Zip Code
Provide the following information pertaining to the requestor.
II. REQUESTOR INFORMATION.
DWC/Representative Box No. (If Applicable):
Name
Address
E-mail Address:
City, State
ZIP
Telephone No.
Fax No.
(
)
(
)
. Please indicate the information and services requested. Service consists of paper copies
III. INFORMATION REQUESTED
of claim information maintained in paper and/or electronic format within the following areas of the Division of Workers’
Compensation files.
Claim File
Certified
Uncertified
Dispute Resolution Contact Data (electronic)
Complete File
Specific Document in File:_______________________
Medical Dispute Resolution File (after 1/1/91)
Certified
Uncertified
Tracking No: ___________________
Medical Dispute Resolution Contact Data (electronic)
Complete File
Specific Document in File:_______________________
Indemnity Dispute Resolution File (claims with a date of injury after 1/1/91 only).
Certified
Uncertified
DWC Docket No: __________________
Complete File
Specific Document in File:_______________________
Video Tape (if available)
CD (if available)
Audio Tape (if available)
Tape Transcription: Hourly Rate
Any questions about a specific file should be directed to the area maintaining the file.
ALL PAGES MUST BE COMPLETED
DWC153
Rev. 10/06
Page
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