Dwc Form-153 Request For Copies Of Confidential Claimant Information Page 3
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1
2
3REQUEST FOR COPIES OF CONFIDENTIAL
CLAIMANT INFORMATION INSTRUCTIONS
(DWC FORM-153)
1.
DWC FORM-153 MUST BE COMPLETED IN ITS ENTIRETY. Please print or type. Submit a separate DWC
FORM- 153 request form for each DWC claim number for which you are requesting copies. We do not accept
faxed or emailed copies. We do not release claimant information except as provided by law.
2.
Section II (Requestor Information) includes a space for an e-mail address. The e-mail address is requested so that
TDI may process the request expeditiously, obtain additional information to complete verification and for billing
purposes. The e-mail address is made confidential under T
. G
’
C
A
. § 552.137 and will not be released
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without your affirmative consent.
3.
A requestor MUST indicate in Section IV the legal basis on which he/she is eligible to receive requested confidential
employee information.
Only individuals in the categories listed are entitled to receive copies of confidential
information. See, Texas Workers' Compensation Act, Texas Labor Code, Section 402.084. See TDI’s website for
additional information. Additional documentation required for eligibility.
A.
An eligible insurance carrier must have handled a workers' compensation claim for the injured worker.
B.
An out of state insurance carrier or employer, or their legal representative, may be eligible to receive
confidential claim file information. Documentation of a workers’ compensation claim against that employer or
the insurance carrier paying that claim must be provided to determine eligibility.
4.
A lay person or a legal representative may represent a claimant or a claimant beneficiary. Other parties eligible to
receive confidential claim file information may authorize a legal representative to request and receive the information
on their behalf. To establish eligibility to receive confidential claim file information, the legal representative of a party
must provide documentation of representation, e.g. letter of representation from client, copy of the contract between
the client and the representative or the defendant’s original answer.
5.
The requestor must swear or affirm to the correctness of the entitlement information before a notary public, sign the
completed form before the notary, and have the notary complete the acknowledgment. The original signed and
notarized form should be mailed or personally delivered to the address indicated at top of DWC FORM-153.
Incorrectly attested forms will be returned without action.
6.
Copies of this form will be accepted if both sides are an exact reproduction of the original and include an original
signature and notarization.
7.
Indicate if a certified copy is requested. The copy of the information requested will have a letter of certification
attached, which is signed or stamped and sealed by the Custodian of Records, or their delegate, attesting to the
authenticity of the attached document(s). See Section III. Certifications are an additional $1.00 fee each.
8.
Charges and billing will be as follows:
A.
Charges exceeding $40 will require approval and estimates over $100 will require a deposit before
documents can be provided/mailed. TDI Agency Counsel will send an itemized statement after the
documents are mailed. Questions regarding billing should be directed to TDI Agency Counsel.
B.
Make checks payable to the Texas Department of Insurance.
9.
No priority mailing is available unless the requestor provides an account number.
10.
For additional assistance in completing this form call the area that maintains the file requested. Records Center file
call (512) 804-4990 x354 or x355; Medical Dispute Resolution file call (512) 804-4812; Indemnity Dispute Resolution
file call (512) 804-4060.
11.
A cancellation of a request must be in writing, call the TDI Agency Counsel section at (512) 475-1757 or one of the
above-listed areas. Cancellation will NOT relieve requestor of responsibility for payment of amounts owed for
services provided PRIOR to notice of cancellation. Any questions regarding billing should be directed to TDI Agency
Counsel at (512) 463-6434.
GOVERNMENTAL AGENCIES/POLITICAL SUBDIVISIONS OR REGULATORY BODIES requesting copies of confidential
claimant information in a capacity other than as an employer, should not complete this form. Please contact DWC Legal
Services at (512) 804-4275 for information concerning determination of eligibility to receive confidential information.
IMPORTANT: BY EXECUTION OF DWC FORM-153, THE REQUESTOR REPRESENTS THAT HE OR SHE IS ENTITLED TO
THE INFORMATION REQUESTED AND THAT HE OR SHE HAS FULL AUTHORITY TO ACT AS A REQUESTOR. IT IS A
CLASS A MISDEMEANOR FOR UNAUTHORIZED PERSONS TO RECEIVE CONFIDENTIAL CLAIM FILE INFORMATION OR
TO DISCLOSE SUCH INFORMATION TO UNAUTHORIZED PERSONS (TEXAS LABOR CODE §§ 402.064; 402.081; 402.083
- .084; 402.086 & 402.091). THE REQUESTOR ALSO ACKNOWLEDGES LIABILITY FOR PAYMENT OF ALL AMOUNTS
OWED FOR SERVICES PROVIDED AS A RESULT OF THIS REQUEST.
DWC153
Rev. 10/06
Page
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