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RME REQUEST

PEER REVIEW REQUEST

DESIGNATED DOCTOR REQUEST

DESIGNATED DOCTOR REQUEST (TWCC32)

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



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



Treating Doctor Name
Treating Doctor License Number
Treating Doctor Phone
Treating Doctor Fax
MD     DC     DO
Attorney Name
Attorney Phone
Attorney Fax
Prior DD Appointment Yes No
Prior DD Appointment Date




Reason for Request:  
To determine if the Employee has reached MMI and, if so, the correct Impairment Rating
To dispute an assigned date of Maximum Medical Improvement and Impairment Rating
To dispute Impairment Rating only
To determine if the Employee’s medical condition has improved sufficiently to allow the employee to return to work (only applicable once employee has reached entitlement to Supplemental Income Benefits – Rule 130.110)

Other Reason (please specify below)
 

Please select the service needed:  
Medical Assessment (physician peer review with nurse summary)
Peer Review Only
Filing Record Only

Comments
 
 



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