Dwc Form-069 - Report Of Medical Evaluation Page 3
Download a blank fillable Dwc Form-069 - Report Of Medical Evaluation in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Dwc Form-069 - Report Of Medical Evaluation with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3DWC069
IMPORTANT INFORMATION FOR INJURED EMPLOYEES:
What if I disagree with the doctor's certification of Maximum Medical Improvement (MMI) and/or permanent impairment rating
for my workers' compensation claim?
If this is the first evaluation of your MMI and/or permanent impairment, you or your representative may dispute:
the certification of MMI; and/or
the assigned impairment rating.
To file the dispute, contact your local DWC field office or call 1-800-252-7031 to request:
the appointment of a designated doctor (DD), if one has not been appointed; or
a Benefit Review Conference (BRC).
Important Note: Your dispute must be filed within 90 days after the written notice is delivered to you or the certification of MMI and/or
the assigned impairment rating may become final.
NOTE: With few exceptions, upon your request, you are entitled to be informed about the information DWC collects about
you; receive and review the information (Government Code, §§552.021 and 552.023); and have DWC correct information that is
incorrect (Government Code, §559.004).
DWC069 Rev. 01/15
Page 3 of 3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal