Get Tx Dwc022 2023-2025

Filling out the TX DWC022 form is an important step in requesting a required medical examination. This guide provides clear guidance to help users navigate each section of the form with confidence, ensuring you complete it accurately online.

Follow the steps to fill out the TX DWC022 form online.

1. Press the ‘Get Form’ button to access the TX DWC022 form and open it for editing.
2. Begin with Section 1, Claim information. In Part 1, provide the employee's full name, Social Security number (last four digits), phone number, address, date of injury, and representative details if applicable.
3. Continue to Part 2 under Insurance carrier information. Fill in the insurance carrier's name, address, adjuster’s name, email, phone number, authorized agent's company name, and contact details for the adjuster.
4. Indicate whether the medical benefits for this claim are from a certified health care network and provide the network's name if applicable. Follow up with any relevant information regarding the political subdivision health care plan if applicable.
5. Move to Section 2, Examination information. Enter the doctor’s name, license number, phone number, and details for the date and time of the examination, along with the location.
6. Answer whether the examination location is more than 75 miles from the employee's address and provide an explanation if necessary.
7. Proceed to Section 3, Purpose of examination. Select either Part 1 or Part 2, marking any relevant issues previously addressed by a designated doctor or details regarding health care appropriateness.
8. If applicable, provide the date of the previous examination and indicate if a different doctor is being requested, including the reason.
9. Complete the employee's agreement to attend the examination and ensure the signature and date are provided.
10. In Section 4, certify the request by signing, including the date, your printed name, and job title.

Start filling out the TX DWC022 form online now to ensure a smooth examination process.