ABOUT US

PRODUCTS

RME REQUEST

PEER REVIEW REQUEST

DESIGNATED DOCTOR REQUEST

DESIGNATED DOCTOR REQUEST (DWC32)

HOME



I don't have time to complete the form. Please send a representative to pick up the file ASAP.



* Adjuster Name
* Carrier Name
Carrier Address
City
State
Zip
Phone
Fax



* Claimant Name (Last, First)
* Claim Number
DWC Number
Claimant Phone
Social Security Number
Date of Injury
Date of Birth
Employer Name
Employer Street Address
City
State
Zip



Treating Doctor Name



Attorney Name
Attorney Phone
Attorney Fax
Prior DD Appointment Yes No
Prior DD Appointment Date



Referrer's Eail Address:



Healthcare Network
In Network
Out Of Network
Name of Network:


Reason for Request:  
Determine maximum medical improvement
Determine the impairment rating
Extent of employee's compensable injury
Disability direct result of work injury
Ability of employee to RTW
Ability of employee to RTW/SIBs
Other

Specific Acceptable Compensable Diagnosis
 

If requesting Extent of Injury, please provide specific injuries/diagnoses in question/dispute
 

Comments
 
 



Medconfirm Inc. •  2001 Bryan Street, Suite 1925 •  Dallas Texas 75201
Main: (214) 370 -3338 •  Fax: (214) 370 -3328