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Get TX DWC053 2008

-1609 (800) 252-7031 (512) 804-4378 fax www.tdi.state.tx.us Carrier claim# EMPLOYEE'S REQUEST TO CHANGE TREATING DOCTOR - NON NETWORK (Form DWC-053) Only the injured employee may use this form to request a change of treating doctor. I. EMPLOYEE INFORMATION 1. Employee's name (last, first, m.i.) 2. Social Security Number 3. Mailing address (street or p.o. box, city/town, state, zip code) 4. Telephone Number ( ) 5. Date of Injury (mm/dd/yyyy) II. EMPLOYER INFORMATION 6. Employer s name.

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