Dwc Form-153 Request For Copies Of Confidential Claimant Information Page 2
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3IMPORTANT: BY EXECUTING THIS FORM, REQUESTOR REPRESENTS THAT HE OR SHE IS ENTITLED
TO THE INFORMATION REQUESTED AND HAS FULL AUTHORITY TO ACT AS A REQUESTOR.
REQUESTOR ALSO ACKNOWLEDGES LIABILITY FOR PAYMENT OF ALL AMOUNTS OWED FOR
SERVICES PROVIDED AS A RESULT OF THIS REQUEST.
IV. REQUESTOR ELIGIBILITY AND NOTARIZATION. (PLEASE CHECK ONE BOX ONLY)
The Texas Workers' Compensation Act, Texas Labor Code, Title 5, Section 402.084, limits the release of confidential
information in or derived from a claim file to the categories of persons listed below. Indicate the category of eligibility, which
qualifies you to receive the information requested. Sign and complete the notarization prior to sending the request to the
Texas Department of Insurance (TDI) Division of Workers’ Compensation (DWC). Eligibility will be verified by TDI DWC.
□
□
The employee or the employee's legal beneficiary
The insurance carrier or insurance carrier’s legal
(ATTACH DOCUMENTATION)
counsel/representative.
(ATTACH DOCUMENTATION)
□
□
The employee's or the legal beneficiary's
The Texas Property and Casualty Insurance
representative
(ATTACH DOCUMENTATION)
Guaranty Association, if that association has
assumed the obligations of an impaired insurance
company
□
□
The employer at the time of injury. Requestor
A third party litigant in a lawsuit, in which the cause
must provide injured employee's period of
of action arises from the incident that gave rise to
employment:
the injury.
(ATTACH DOCUMENTATION)
(COPY OF PETITION AND ANSWER MUST BE
Requestor must provide injured
ATTACHED).
employee's date of injury
to
mo./yr
mo./yr.
mo/yr
□
□
The Texas Certified Self-Insurer Guaranty
Health Care Provider who is a party to a Medical
Association Established under Subchapter G,
Dispute (Section 413.031 of the Act)
Chapter 407, if that association has assumed the
obligations of an impaired employer.
I have read and understand this form and the accompanying instructions. I am entitled to receive the confidential employee
information being requested as indicated above. I understand that it is a Class A misdemeanor to unlawfully receive,
publish, disclose, or distribute confidential information in or derived from an employee's claim file. [Texas Labor Code,
Sections 402.064; 402.081; 402.083 - .084; 402.086 and 402.091]
Name of Requestor:
(Please Print)
Position/Title:
Firm Name:
(if applicable)
Federal Tax I.D.#:
Signature:
Date
State of
*
*
County of
*
Before me on the above date personally appeared
,
who after first being sworn or affirmed, said that the statements contained in this request are true.
Signed
Notary Public, State of
My Commission Expires
DWC153
Rev. 10/06
Page
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