Dwc Form-069 - Report Of Medical Evaluation Page 2
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Frequently Asked Questions
Report of Medical Evaluation (DWC Form-069)
INSTRUCTIONS FOR DOCTORS:
Who can file the DWC Form-069?
Treating Doctor: Doctor chosen by the employee who is primarily responsible for employee's injury-related health care.
Doctor Selected by Treating Doctor:
Doctor selected by the treating doctor to evaluate permanent impairment and
Maximum Medical Improvement (MMI). This doctor acts in the place of the treating doctor. Such a doctor must be selected if
the treating doctor is not authorized to certify MMI or assign an impairment rating in those cases in which the employee has
permanent impairment.
An authorized treating doctor may also choose to select another doctor to perform the
evaluation/certification.
Designated Doctor: Doctor selected by the Texas Department of Insurance, Division of Workers’ Compensation (DWC) to
resolve a question over MMI or permanent impairment.
Insurance Carrier-Selected RME Doctor: Doctor selected by the insurance carrier to evaluate MMI and/or permanent
impairment. An insurance carrier-selected Required Medical Examination (RME) Doctor is only authorized to certify MMI,
evaluate permanent impairment, and assign an impairment rating when specifically approved by DWC prior to the examination
and only after a designated doctor has completed the same.
AUTHORIZATION: In addition to the requirement of acting in an eligible role, 28 Texas Administrative Code §130.1 provides the
following requirements:
Employee has permanent impairment: Only a doctor certified by DWC to assign impairment ratings or who receives specific
permission by exception granted by DWC is authorized to certify MMI and to assign an impairment rating.
Employee does not have permanent impairment: A doctor not certified or exempted from certification by DWC is only
authorized to determine whether an employee has permanent impairment and, in the event that the employee has no
impairment, certify MMI.
INVALID CERTIFICATION: Certification by a doctor who is not authorized is invalid.
Under what circumstances and when am I required to file the DWC Form-069?
If the employee has reached MMI, you must file the DWC Form-069 no later than the seventh working day after the later of: (a) date of
the certifying examination; or (b) receipt of all medical information necessary to certify MMI. Only a Designated Doctor is subject to this
requirement if the employee has not reached MMI.
Where do I file the form?
The DWC Form-069 and required narrative shall be filed with:
the insurance carrier;
the treating doctor (if a doctor other than the treating doctor files the report);
DWC;
injured employee; and
injured employee’s representative (if any).
The report must be filed by facsimile or electronic transmission unless an exception applies. The specific requirements are shown
below. To file this form with DWC, fax to (512) 490-1047
.
Treating Doctor
Injured Employee
Insurance Carrier
DWC
Injured Employee’s Representative
fax or e-mail unless recipient has not
Designated Doctor
fax or e-mail
fax or e-mail
provided these numbers; then by other
verifiable means
Treating Doctor
fax or e-mail unless recipient has
fax or e-mail unless recipient has not
Doctor Selected by Treating Doctor
fax or e-mail
not provided these numbers; then
provided these numbers; then by other
Insurance Carrier-Selected RME Doctor
by other verifiable means
verifiable means
Do I have to maintain documentation regarding the examination and report?
The certifying doctor must maintain the original copy of the report and narrative and documentation of the following:
date of the examination;
date any medical records necessary to make the certification of MMI were received, and from whom the medical records were
received; and
date, addresses, and means of delivery that required reports were transmitted or mailed by the certifying doctor.
Where can I find more information about the Report of Medical Evaluation?
See 28 TAC §130.1 through §130.4 and §130.6 for the complete requirements regarding the filing of this report, including required
documentation.
The complete text of these rules is available on the Texas Department of Insurance website at
If you have additional questions, call 1-800-372-7713, Option #3.
DWC069 Rev. 01/15
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