Dwc Form-053, Employee Request To Change Treating Doctor
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1
2DWC053
Texas Department of Insurance
Complete if known:
Division of Workers’ Compensation
DWC Claim #
7551 Metro Center Drive, Suite 100 • MS-94
Austin, TX 78744-1645
Carrier Claim #
(800) 252-7031 phone • (512) 804-4378 fax
Employee Request to Change Treating Doctor
For use ONLY by Employees NOT in Workers’ Compensation Health Care Networks or Certain Political Subdivision Health Care Plans
Type (or print in black ink) each item on this form
I. EMPLOYEE/EMPLOYEE’S ATTORNEY INFORMATION
1. Employee's Name
2. Employee’s Social Security Number
(First, Middle, Last)
3. Employee’s Mailing Address
(Street or PO Box, City, State, Zip Code)
4. Employee’s Telephone Number
5. Alternate Telephone Number
6. Date of Injury
(if available)
(mm/dd/yyyy)
(
)
(
)
7. Attorney/Representative’s Name
8. Attorney/Representative’s Address
(if applicable)
(Street or PO Box, City, State, Zip
Code)
II. EMPLOYER INFORMATION (at the time of the injury)
9. Employer’s Name
10. Employer’s Address
(Street or PO Box, City, State, Zip Code)
III. INSURANCE CARRIER INFORMATION
11. Insurance Carrier's Name
12. Insurance Carrier's Address
(Street or PO Box, City, State, Zip Code)
13. Adjuster’s Name
14. Adjuster’s Telephone Number
15. Adjuster’s Fax Number
(
)
ext.
(
)
IV. TREATING DOCTOR INFORMATION
Current Treating Doctor
16. Current Treating Doctor's Name
and Title
17. Current Treating Doctor’s Telephone Number
(First, Middle, Last)
(MD, DO, DC, etc.)
(
)
ext.
18. Current Treating Doctor's Mailing Address
(Street or P.O. Box, City, State, Zip Code)
19. Current Treating Doctor’s License Number
20. Current Treating Doctor’s Fax Number
(if known)
(
)
Reason for Requesting a Change of Treating Doctor
21. Explain Why You Are Requesting to Change Your Treating Doctor
(Attach additional sheets if necessary.)
Requested Treating Doctor
22. Requested Treating Doctor's Name
and Title
23. Requested Treating Doctor's Telephone Number
(First, Middle, Last)
(MD, DO, DC, etc.)
(
)
ext.
24. Requested Treating Doctor’s License Number
25. Requested Treating Doctor’s Fax Number
(
)
26. Requested Treating Doctor’s Mailing Address
(Street or P.O. Box, City, State, Zip Code)
27. Requested Treating Doctor's Signature
28. Date
(required)
(mm/dd/yyyy)
V. EMPLOYEE'S AUTHORIZATION TO CHANGE TREATING DOCTORS AND RELEASE MEDICAL RECORDS
For TDI-DWC Use Only
By signing this form I confirm that I wish to change my treating doctor, and I authorize my current treating
doctor to furnish records pertaining to my workers' compensation claim to the requested treating doctor.
29. Employee's Signature
(required)
30. Date
NOTE: With few exceptions, upon your request, you are entitled to be informed about information TDI-DWC collects about you; receive and review
the information (Government Code, §§552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government Code, §559.004).
DWC053 Rev. 03/12
Page 1 of 2
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