Dwc Form-053, Employee Request To Change Treating Doctor Page 2
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Frequently Asked Questions
Employee Request to Change Treating Doctor (DWC Form-053)
For use ONLY by Employees NOT in Workers’ Compensation Health Care Networks or Certain Political Subdivision Health Care Plans
Who may use this form to change treating doctors?
Only an injured employee (a) who is covered by the Texas workers’ compensation system; (b) who has a claim with a date of
injury or exposure on or after January 1, 1991; (c) who is not part of a c ertified workers’ compensation health care network
(network); and (d) whose claim does not involve medical benefits provided through a political subdivision (political subdivision
health plan) pursuant to §504.053(b)(2) of the Texas Labor Code, relating to directly contracting with health care providers or
contracting through a health benefits pool may use this form to request a change of treating doctor.
NOTE: If you are in a network described in (c) above or a health plan described in (d) above, contact the network or health plan and follow
their procedures for changing your treating doctor. If you do not know if you are in a network or this type of health plan, contact your workers’
compensation insurance adjuster.
Under what circumstances am I required to file the DWC Form-053?
You must file the DWC Form-053 to request Texas Department of Insurance, Division of Workers’ Compensation (TDI-
DWC) approval before receiving services from a new treating doctor if you are dissatisfied with the initial choice of treating
doctor for a valid reason including, but not limited to:
•
you believe treatment provided by your current treating doctor is medically inappropriate;
•
you believe you are not receiving appropriate medical care to reach maximum medical improvement;
•
you are concerned about the professional reputation of your current treating doctor;
•
there is a conflict between you and your current treating doctor to the extent that the doctor-patient relationship is
jeopardized or impaired; or
•
your current treating doctor chooses not to coordinate your health care because of communication issues
between the doctor and the insurance carrier regarding the processing of your medical bills. Provide
documentation from your current treating doctor, if available.
You may not request a change of treating doctor to obtain a new impairment rating or medical report.
IMPORTANT NOTE: If you fail to obtain TDI-DWC approval prior to receiving treatment from the new treating doctor, you may be responsible
for the cost of treatment and the insurance carrier may be relieved of responsibility for payment. In order to obtain TDI-DWC approval, you
must file the DWC Form-053 unless an immediate change of treating doctor is medically necessary. In that case, you may contact the TDI-
DWC field office handling your claim by telephone to obtain verbal approval.
You must also file the DWC Form-053 to immediately notify the TDI-DWC if you change treating doctors because:
•
you moved or changed residence; or
•
your current treating doctor is unavailable or unable to provide medical care or has retired or died. Provide
documentation from the doctor’s office, if available.
Why is the new treating doctor’s signature required?
You must confirm that the requested doctor will treat you by contacting the requested doctor’s office, describing your injury and
asking if the doctor is taking new workers’ compensation patients. To verify that the doctor has agreed to treat you, you must
have the doctor sign the DWC Form-053 in Box 27. The treating doctor must be a doctor as defined in the Texas Labor Code
401.011. A non-physician practitioner, e.g. a nurse practitioner or a physician’s assistant, cannot be a treating doctor.
§
Where do I file the DWC Form-053?
You can submit the form and any supporting documentation to the TDI-DWC by:
•
fax to (512) 804-4378; or
•
mail to the Texas Department of Insurance, Division of Workers’ Compensation, 7551 Metro Center Drive, Suite 100,
MS-94, Austin, Texas 78744-1645.
What does the TDI-DWC do?
Within 10 days of receiving the signed DWC Form-053, the TDI-DWC will review and process the request.
•
If the request is approved, the TDI-DWC will issue an approval order and send a copy to the injured employee,
injured employee’s representative (if any), insurance carrier, prior treating doctor and newly approved treating
doctor.
•
If the request is denied, the TDI-DWC will issue a denial order and send a copy to the injured employee, injured
employee’s representative (if any), insurance carrier and requested treating doctor.
NOTE: If you do not agree with the TDI-DWC’s decision, you must dispute the decision within 10 days of receiving the order. Contact the TDI-
DWC field office handling the claim at 1-800-252-7031 for more information about the dispute process. The insurance carrier also has the right
to dispute the decision.
DWC053 Rev. 03/12
Page 2 of 2
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