A treating doctor or certifying doctor who determines that an injured employee has reached MMI and assigns an IR shall provide the injured employee with a written notice that the certification may be disputed. That notice shall be provided as a separate document included with the DWC Form-069, Report of Medical Evaluation, which is required by 28 TAC §130.1, and must be provided in English, Spanish or any other language common to the injured employee. The notice must include the following information:
• the date of MMI;
• the assigned IR;
• a statement that the IR may become final if not disputed within 90 days, and if the injured employee, or the injured employee’s representative, disagrees with the certification, they may dispute the certification by contacting the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) and requesting a benefit review conference;
• the address and telephone number of the local TDI-DWC field office; and
• a statement that the injured employee may contact the TDI-DWC for more information at
1-800-252-7031.
• the assigned IR;
• a statement that the IR may become final if not disputed within 90 days, and if the injured employee, or the injured employee’s representative, disagrees with the certification, they may dispute the certification by contacting the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) and requesting a benefit review conference;
• the address and telephone number of the local TDI-DWC field office; and
• a statement that the injured employee may contact the TDI-DWC for more information at
1-800-252-7031.
Sample notices are available in English, Spanish, Chinese and Vietnamese on the TDI website at www.tdi.state.tx.us/wc/hcprovider/documents/hcpsampleirmmi.pdf.
We encourage you to forward this memo to your colleagues who participate in the Texas workers’ compensation system.
