Get Tx Dwc121 2020-2025

The TX DWC121 form is essential for submitting claim administration contact information for insurance carriers in Texas. This guide provides clear, step-by-step instructions for filling out the form online, ensuring a smooth and efficient process for all users.

Follow the steps to successfully complete the TX DWC121 form online.

1. Click ‘Get Form’ button to retrieve the TX DWC121 form and open it in your editing tool.
2. Fill in the contact information for the Austin representative, including their name, organization, address, phone number, fax number, and email address.
3. Next, provide the insurance carrier’s details by entering the insurance carrier's name, federal employer identification number, group affiliation (if applicable), mailing address, and contact information.
4. Select one of the options available for claim administration contact information. If opting for a web address, enter the effective date and the URL of the webpage.
5. If not using the web address, fill out the claim adjustment section with relevant business information, effective date, address, email, phone, and fax details.
6. Proceed to cover verification, medical billing, pharmacy billing, preauthorization, and the workers’ compensation health care network sections, inputting the required details for each and ensuring all fields are complete.
7. Conclude by providing your signature as the Austin representative, printing your name, and entering the date of your signature.
8. After completing all sections, save your changes, and choose to download, print, or share the form as needed.

Complete the TX DWC121 form online now to ensure your claim administration contact details are up-to-date.