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Get TX DWC053 2012-2024

E (512) 804-4378 fax Carrier Claim # 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 (First, Middle, Last) 2. Employee s Social Security Number 3. Employee s Mailing Address (Street or PO Box, City, State, Zip Code) 4. Employee s Telephone Numb.

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