Get the free Employee's Request to Change Treating Doctor - Non Network (Form DWC-053)
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This form is used by injured employees to request a change of their treating doctor in the Texas workers' compensation system.
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How to fill out employees request to change
How to fill out Employee's Request to Change Treating Doctor - Non Network (Form DWC-053)
01
Obtain the Employee's Request to Change Treating Doctor - Non Network (Form DWC-053) from your state's workers' compensation website or office.
02
Fill in your personal information, including your name, address, phone number, and claim number at the top of the form.
03
Provide details about your current treating doctor, including their name, address, and phone number.
04
Indicate the reason for your request to change your treating doctor in the designated section.
05
Complete the information for the new doctor you wish to see, including their name, address, and the specialty.
06
Sign and date the form to confirm that the information you provided is accurate.
07
Submit the completed form to your employer and the workers' compensation claims administrator, and keep a copy for your records.
Who needs Employee's Request to Change Treating Doctor - Non Network (Form DWC-053)?
01
Employees who are currently undergoing treatment for a work-related injury or illness and wish to change their treating doctor to a different doctor within a non-network provider.
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What is Employee's Request to Change Treating Doctor - Non Network (Form DWC-053)?
The Employee's Request to Change Treating Doctor - Non Network (Form DWC-053) is a form used by employees to formally request a change in their treating physician when they are seeking treatment outside of the approved network of doctors.
Who is required to file Employee's Request to Change Treating Doctor - Non Network (Form DWC-053)?
Employees who are currently under workers' compensation and wish to change their treating doctor from a network provider to a non-network provider are required to file Form DWC-053.
How to fill out Employee's Request to Change Treating Doctor - Non Network (Form DWC-053)?
To fill out Form DWC-053, employees need to provide their personal details, including their name, address, and claim information, as well as the current treating doctor’s information and the proposed new non-network doctor’s information.
What is the purpose of Employee's Request to Change Treating Doctor - Non Network (Form DWC-053)?
The purpose of Form DWC-053 is to ensure that employees have a formal process to request a change of their treating doctor when the current doctor is not meeting their medical needs or if they wish to seek care from a non-network provider.
What information must be reported on Employee's Request to Change Treating Doctor - Non Network (Form DWC-053)?
The information that must be reported includes the employee's name, contact information, claim number, details of the current treating doctor, the name of the new requested non-network doctor, and the reasons for the change.
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