Get Tx Tdi Dwc049 2017-2025

This guide provides a detailed overview of how to efficiently fill out the TX TDI DWC049 form online. By following these steps, users can ensure accurate submission for a medical contested case hearing.

Follow the steps to successfully complete the TX TDI DWC049 form online.

1. Click ‘Get Form’ button to obtain the form and open it in your online editor.
2. Begin with Section I, REQUEST SPECIFICATIONS. Here, check the appropriate box to indicate the type of medical contested case hearing you are requesting. This includes an appeal of an Independent Review Organization (IRO) medical necessity decision or an appeal of a medical fee dispute decision. Remember to attach a copy of the IRO decision if applicable.
3. Continue by checking any applicable boxes for the type of services you are requesting, such as expedited MCCH or special accommodations. Specify the reasons where necessary.
4. In Section II, INJURED EMPLOYEE CLAIM INFORMATION, fill out the employee’s name, date of injury, physical address, and the names of the insurance carrier and employer’s business at the time of injury.
5. Proceed to Section III, REQUESTER INFORMATION. Indicate who is making the request by checking the appropriate box. Provide further details including whether the injured employee is a first responder and whether they are assisted by the Office of Injured Employee Counsel (OIEC).
6. Complete the requester's mailing address, printed name/title, phone number, signature, and the date of signature. Ensure all required fields are filled accurately.
7. After reviewing your completed form, save changes, download, print, or share the form as needed, ensuring to keep a copy for your records.

Start completing your TX TDI DWC049 form online today to ensure your request is submitted correctly and efficiently.