Get Dwc069 Form

Filling out the DWC069 Form online provides an efficient way to submit a medical evaluation report for workers' compensation claims in Texas. This guide will help you navigate each section of the form with clarity and confidence.

Follow the steps to successfully complete the DWC069 Form online.

1. Click ‘Get Form’ button to obtain the DWC069 Form and open it in your preferred editor.
2. Enter the necessary general information, including the injured employee's name, employer's details, and the date of injury in the appropriate fields. Make sure all entries are accurate to ensure proper processing.
3. Specify the certifying doctor's information. This includes their name, license type, license number, and jurisdiction. Fill in the doctor's phone and fax numbers as well.
4. Indicate the role of the doctor in the claim for the evaluation by selecting from the provided options. Ensure that the role aligns with the eligibility as per Texas Administrative Code §130.1.
5. Document the medical status by providing the date of examination and the employee’s diagnosis, ensuring to use the correct ICD-9 codes.
6. Determine whether the employee has reached Clinical or Statutory Maximum Medical Improvement (MMI), and check the appropriate box to certify.
7. If applicable, assess and indicate any permanent impairment resulting from the compensable injury, providing correct percentages if there is impairment.
8. Complete the doctor’s certification section, ensuring all information is true and complies with applicable laws, then include your signature and the date of certification.
9. If the treating doctor agrees or disagrees with the certifying doctor's evaluation, they must complete their section, providing their details and signature.
10. Finally, review the entire form for accuracy, save your changes, and then download, print, or share the completed DWC069 Form as necessary.

Complete your DWC069 Form online today for a smoother filing process.