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The 53 Form for Doctors

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Submitted By THCM
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DWC053

Texas Department of Insurance
7551 Metro Center Drive, Suite 100 • MS-94 Austin, TX 78744-1645 (800) 252-7031 phone • (512) 804-4378 fax

Division of Workers’ Compensation

Complete if known: DWC Claim # Carrier Claim #

Employee Request to Change Treating Doctor
For use ONLY by Employees NOT in Workers’ Compensation Health Care Networks or Certain Political Subdivision Health Care Plans Type (or print in black ink) each item on this form

I. EMPLOYEE/EMPLOYEE’S ATTORNEY INFORMATION
1. Employee's Name (First, Middle, Last) 3. Employee’s Mailing Address (Street or PO Box, City, State, Zip Code) 4. Employee’s Telephone Number ( ) 7. Attorney/Representative’s Name (if applicable) 5. Alternate Telephone Number (if available) 6. Date of Injury (mm/dd/yyyy) ( ) 8. Attorney/Representative’s Address (Street or PO Box, City, State, Zip
Code)

2. Employee’s Social Security Number

II. EMPLOYER INFORMATION (at the time of the injury)
9. Employer’s Name 10. Employer’s Address (Street or PO Box, City, State, Zip Code)

III. INSURANCE CARRIER INFORMATION
11. Insurance Carrier's Name 13. Adjuster’s Name 12. Insurance Carrier's Address (Street or PO Box, City, State, Zip Code) 14. Adjuster’s Telephone Number ( ) ext. 15. Adjuster’s Fax Number ( )

IV. TREATING DOCTOR INFORMATION Current Treating Doctor
16. Current Treating Doctor's Name (First, Middle, Last) and Title (MD, DO, DC, etc.) 18. Current Treating Doctor's Mailing Address (Street or P.O. Box, City, State, Zip Code) 19. Current Treating Doctor’s License Number (if known) 20. Current Treating Doctor’s Fax Number ( ) 17. Current Treating Doctor’s Telephone Number ( ) ext.

Reason for Requesting a Change of Treating Doctor
21. Explain Why You Are Requesting to Change Your Treating Doctor (Attach additional sheets if necessary.)

Requested Treating Doctor
22. Requested Treating Doctor's…...

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