Get the free DWC Form-064, Medical Interlocutory Order Request - tdi texas

DWC064 Texas Department of Insurance Division of Workers Compensation Fax Completed Form To: (512) 804-4874 7551 Metro Center Drive, Suite100 MS-41 Austin, TX 78744-1645 (512) 804-4000 phone (512)

How to fill out dwc form-064 medical interlocutory

How to fill out dwc form-064 medical interlocutory:

1. Start by entering the date at the top of the form.
2. Clearly write your name and contact information in the designated spaces.
3. Provide the case number and name of the injured worker for whom the form is being filled.
4. State the injured worker's occupation and employment history.
5. Describe the medical condition or injury for which the interlocutory is being filed.
6. Include a detailed account of the medical treatment received by the injured worker.
7. Attach any relevant medical reports or documentation to support the claim.
8. Sign the form and include the date of signature.

Who needs dwc form-064 medical interlocutory:

1. Employers or insurance carriers involved in workers' compensation cases may need to fill out this form.
2. The injured worker's attorney or representative may also be required to complete the form.
3. Medical professionals who are treating the injured worker and need to provide detailed information about the medical condition may need to use this form.

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What is dwc form-064 medical interlocutory?

DWC Form-064 Medical Interlocutory is a form used in the workers' compensation system to request additional medical treatment or modify existing treatment for a work-related injury.

Who is required to file dwc form-064 medical interlocutory?

The injured worker, their legal representative, or the authorized treating physician may be required to file DWC Form-064 Medical Interlocutory.

How to fill out dwc form-064 medical interlocutory?

To fill out DWC Form-064 Medical Interlocutory, the required fields must be completed with accurate information regarding the injured worker, their employer, the requested treatment, and any supporting medical documentation.

What is the purpose of dwc form-064 medical interlocutory?

The purpose of DWC Form-064 Medical Interlocutory is to facilitate communication between the injured worker, their legal representative, and the workers' compensation system to ensure proper medical treatment and support for work-related injuries.

What information must be reported on dwc form-064 medical interlocutory?

DWC Form-064 Medical Interlocutory requires information such as the injured worker's name, contact details, treating physician's information, employer information, details of the injury, requested treatment or modification, and any supporting medical documentation.