Fillable Printable Designated Doctor Certification Application
Fillable Printable Designated Doctor Certification Application
Designated Doctor Certification Application
DWC067
DWC067 Rev. 8/16 Page 1 of 6
DESIGNATED DOCTOR CERTIFICATION APPLICATION
Initial Certification
Recertification
Date current certification expires, if applicable
(mm/yyyy)
I. APPLICANT / INDIVIDUAL INFORMATION (not administrative services company/agent information)
1. Name
(Last, First, Middle, Suffix)
2. Social Security Number
3. Date of Birth
(mm/dd/yyyy)
4. Home Mailing Address
(Street or PO Box, City, State, ZIP Code)
5. Business Mailing Address (Street or PO Box, City, State, ZIP Code)
6. Home Phone Number
( )
7. Business Phone Number
( )
8. Cell Phone Number
( )
9. Fax Number
( )
10. E-mail Address
11a. Non-English Language Spoken by Applicant
Yes No
If yes, specify
11b. Non-English Language Spoken by Office Personnel
Yes No
If yes, specify
II. LICENSE INFORMATION (attach additional pages, if necessary)
Texas License Other License (if applicable) Other License (if applicable)
12. License Type
17. License Type
22. License Type
13. License Number
18. License Number
23. License Number
14. State of Registration
Texas
19. State of Registration
24. State of Registration
15. Original Date of Issue
(mm/yyyy)
20. Original Date of Issue
(mm/yyyy)
25. Original Date of Issue
(mm/yyyy)
16. Expiration Date (mm/yyyy)
21. Expiration Date (mm/yyyy)
26. Expiration Date (mm/yyyy)
For TDI-DWC Use Only
DWC067
DWC067 Rev. 8/16 Page 2 of 6
III. PROFESSIONAL SPECIALTY INFORMATION - MD/DO ONLY (attach additional pages, if necessary)
List professional specialties
Provide the applicable dates
(mm/yyyy)
27. Primary Specialty:
Indic
ate your board certification for this specialty.
ABMS AOABOS None
Initial certification:
Recertification(s):
Expiration:
28. Secondary Specialty:
Indi
cate your board certification for this specialty.
ABMS AOABOS None
Initial certification:
Rece
rtification(s):
Expirat
ion:
29. Additional Specialty:
Indic
ate your board certification for this specialty.
ABMS AOABOS None
Initial certification:
Rece
rtification(s):
Expiration:
NOTE: The applicant may be required to present ABMS or AOABOS documentation for verification purposes.
IV. EDUCATION (attach additional pages, if necessary)
30. Professional Degree
Medical/Osteopathic Chiropractic Optometry Podiatry Dentistry
31. Institution
32. Degree
33. Attendance Dates (mm/yyyy)
From to
34. Address
(Street or PO Box, City, State, ZIP Code)
35. Post-Graduate Education
Internship Residency Fellowship
Teaching Appointment
36. Program Director
37. Current Program Director
(if known)
38. Institution
39. Program Specialty
40. Attendance Dates
(mm/yyyy)
From to
41. Address
(Street or PO Box, City, State, ZIP Code)
42. Program Completed Successfully
Yes No
43. Post-Graduate Education
Internship Residency Fellowship
Teaching Appointment
44. Program Director
45. Current Program Director
(if known)
46. Institution
47. Program Specialty
48. Attendance Dates
(mm/yyyy)
From to
49. Address (Street or PO Box, City, State, ZIP Code)
50. Program Completed Successfully
Yes No
51. Other Graduate-Level Education
(field of study)
52. Institution
53. Degree
54. Attendance Dates
(mm/yyyy)
From to
55. Address (Street or PO Box, City, State, ZIP Code)
Applicant’s Name:
Texas License #:
For TDI-DWC Use Only
DWC067
DWC067 Rev. 8/16 Page 3 of 6
V. ACTIVE PRACTICE / WORK HISTORY INFORMATION
Active Practice
56. Have you maintained an active practice* for at least 3 years?
Yes No
* Active practice is defined as maintaining routine office hours of at least 20 hours per week for 40 weeks per year for the
treatment of patients.
Work History (attach additional pages, if necessary)
57. Current Practice / Employer Name
(if any)
58. Start Date / End Date
(mm/yyyy)
From to
59. Address
(Street or PO Box, City, State, ZIP Code)
60. Previous Practice / Employer Name
61. Start Date / End Date
(mm/yyyy)
From to
62. Address (Street or PO Box, City, State, ZIP Code)
63. Previous Practice / Employer Name
64. Start Date / End Date
(mm/yyyy)
From to
65. Address
(Street or PO Box, City, State, ZIP Code)
66. Previous Practice / Employer Name
67. Start Date / End Date
(mm/yyyy)
From to
68. Address
(Street or PO Box, City, State, ZIP Code)
VI. WORKERS’ COMPENSATION HEALTH CARE NETWORK AFFILIATIONS
List all current workers’ compensation health care network (network) affiliation(s) pursuant to
Insurance Code §1305 and affiliation(s) with political subdivision health care plan(s) pursuant to Texas
Labor Code §504.053(b)(2). Enter the contract start date for each network and each health care plan.
(attach additional pages, if necessary)
69. Network / Health Care Plan Name
70. Start Date
(mm/dd/yyyy)
71. Network / Health Care Plan Name
72. Start Date (mm/dd/yyyy)
73. Network / Health Care Plan Name
74. Start Date
(mm/dd/yyyy)
VII. ADMINISTRATIVE SERVICES COMPANY / BILLING AGENT / OTHER AGENT AFFILIATIONS
List all current administrative services company, billing agent, and other agent affiliation(s)
(attach additional pages, if necessary)
75. Administrative Services Company / Agent Name
76. Contract Start Date
(mm/dd/yyyy)
77. Administrative Services Company / Agent Address
(Street or PO Box, City, State, ZIP Code)
78. Name of Point of Contact
79. Phone Number of Point of Contact
( )
80. E-mail Address of Point of Contact
81. Fax Number of Point of Contact
( )
82. Billing Agent Name
83. Billing Agent Phone Number
( )
Applicant’s Name:
Texas License #:
For TDI-DWC Use Only
DWC067
DWC067 Rev. 8/16 Page 4 of 6
VIII. DISCLOSURE QUESTIONS (check YES or NO for each question)
84. Licensure
YES
NO
Has your license to practice, in your profession, ever been denied, suspended, revoked, restricted, voluntarily
surrendered while under investigation, or have you ever been subject to a consent order,
disciplinary action,
remedial plan, probation or any conditions or limitations by any state licensing board or state or federal agency
,
including TDI-DWC?
Have you or your professional practice ever received a reprimand or been fined by any state licensing board or
state or federal agency, including TDI-DWC?
85. Hospital Privileges and Other Affiliations
YES
NO
Have your clinical privileges or medical staff membership at any hospital or health care institution ever been
denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary
conditions (for reasons other than non-completion of medical records when quality of care was no
t adversely
affected) or have proceedings toward any of those ends been instituted or recommended by any hospital or
health care institution, medical staff or committee, or governing board?
Have you ever voluntarily surrendered, limited your privileges or not reapplied for privileges while under
investigation?
Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any
disciplinary action, by any managed care organizations (including HMOs, PPOs, or provider organizations such
as IPAs, PHOs)?
86. Education, Training and Board Certification
YES
NO
Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an
internship, residency, fellowship,
preceptorship or other clinical education program? If you are currently in a
training program, have you been placed on probation, disciplined, formally reprimanded, suspended or asked
to resign?
Have you ever, while under investigation, voluntarily withdrawn or prematurely terminated your status as a
student or employee in any internship, residency, fellowship, preceptorship, or other
clinical education
program?
Have any of your board certifications or eligibility ever been revoked?
Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under
investigation?
87. DEA (Drug Enforcement Administration) or DPS (Department of Public Safety)
YES
NO
Have your Federal DEA and/or DPS Controlled Substances Certificate(s) or authorization(s) ever been denied,
suspended, revoked, restricted, denied renewal, or voluntarily relinquished?
88. Medicare, Medicaid or other Governmental Program Participation
YES
NO
Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured,
disqualified or
otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard
to other federal or state governmental health care plans or programs?
Other sanctions or investigations?
Are you currently or have you ever been the subject of an investigation by any hospital, licensing authority,
DEA or
DPS authorizing entities, education or training program, Medicare or Medicaid program, or any other
private, federal or state health program?
To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data
Bank or Healthcare Integrity and Protection Data Bank?
Have you ever received sanctions from or been the subject of investigation by any regulatory agency (e.g., CLIA,
OSHA, etc.)?
Applicant’s Name:
Texas License #:
For TDI-DWC Use Only
DWC067
DWC067 Rev. 8/16 Page 5 of 6
NOTE: With few exceptions, upon your request, you are entitled to be informed about the information TDI-DWC collects about you; get and
review the information (Government Code, §§552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government
Code, §559.004). For more information, contact agencycounsel@tdi.texas.gov or you may refer to the Corrections Procedure
section at
www.tdi.texas.gov.
Have you ever been investigated, sanctioned, reprimanded or cautioned by a military hospital, facility, or
agency?
Have you ever been terminated or resigned while under investigation by a hospital or health care facility of any
military agency?
89. Malpractice Claims History
YES
NO
Have you had any active/pending malpractice claims/actions at any time during the past 5 years?
90. Criminal
YES
NO
Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony that is reasonably related
to your qualifications, competence, functions, or duties as a medical professional?
Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony including an act of
violence, child abuse or a sexual offense?
Have you ever been court-martialed for actions related to your duties as a medical professional?
91. Ability to Perform Job
YES
NO
Are you currently engaged in the illegal use of drugs?
NOTE:
"Currently" means sufficiently recent to justify a reasonable belief that the use of drug may have an
ongoing impact on one's ability to practice one's profession
. It is not limited to the day of, or within a matter
of days or weeks before the date of appl
ication, rather that it has occurred recently enough to indicate the
individual is actively engaged in such conduct. "Illegal use of drugs" refers to drugs whose possession or
distribution is unlawful under the Controlled Substances Act, 21 U.S.C. §812.22. It "does not include the use of
a drug taken under supervision by a licensed health care professional, or other uses authorized by the
Controlled Substances Act or other provision of Federal law." The term does include, however, the unlawful
use of prescription controlled substances.
Do you use any chemical substances that would in any way impair or limit your ability to practice your
profession and perform the functions of your job with reasonable skill and safety?
Do you have any reason to believe that you would pose a risk to the safety or well-being of injured employees
or other system participants?
Are you unable to perform the essential functions of a designated doctor as specified in 28 Texas Administrative
Code, Chapter 127 and other applicable provisions of TDI-DWC rules and the Texas Labor Code?
92. Disclosure Explanations (attach additional pages, if necessary)
If you answered “Yes” to any question(s), identify each question by number and explain below.
Applicant’s Name:
Texas License #:
For TDI-DWC Use Only
DWC067
DWC067 Rev. 8/16 Page 6 of 6
IX. APPLICANT’S AUTHORIZATION, ATTESTATION AND RELEASE
I authorize any third party, including, but not limited to, individuals, agencies, medical groups responsible for credentials
verification, corporations, companies, employers, former employers, hospitals, health plans, health maintenance
organizations, man
aged care organizations, law enforcement or licensing agencies, insurance companies, educational and
other institutions, medical credentialing and accreditation agencies, professional medical societies, the Federation of State
Medical Boards, the National
Practitioner Data Bank, and the Health Care Integrity and Protection Data Bank, to release to the
Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC), information, including otherwise privileged or
confidential information, concernin
g my professional qualifications, credentials, clinical competence, quality assurance and
utilization data, character, mental condition, physical condition, alcohol or chemical dependency diagnosis and treatment,
ethics, behavior, or any other matter reasonably having a bearing on my qualifications for participation in, or with, the TDI-
DWC. I specifically waive written notice from any entities and individuals who provide information based upon this
Authorization, Attestation and Release.
I certify that all information provided in this application is true, complete, and correct to the best of my knowledge. I understand
that I am required on my own initiative to report to the TDI-DWC any updated information within 10 working days of a change
in any of the information provided to the division on the doctor’s application for certification or recertification as a designated
doctor.
I am aware that participation in the Texas workers' compensation system as a designated doctor is not a right and is conditioned
upon compliance with Title 5 of the Labor Code and TDI-DWC rules and my provision of quality health care, evaluations, and/or
medical opinions.
I affirm that I will remain aware of and in compliance with the requirements of the statutes and TDI-DWC rules, including but
not limited to:
• financial disclosure requirements as contained in the Labor Code §413.041;
• cooperating with TDI-DWC monitoring and review efforts such as audits by the TDI-DWC;
• paying audit bills when required by statute or rule;
• providing updated information under TDI-DWC rules §127.200(a)(8);
• consenting to any on-site inspections consistent with TDI-DWC rules §127.200(a)(15); and
• owning or maintaining subscriptions to the current editions of guidelines adopted by the TDI-DWC, including
impairment rating, treatment, and return-to-work guidelines.
I understand and agree that any material misstatement or omission in the application may result in delay, denial, revocation,
and/or immediate suspension or termination of certification.
93. Signature of Applicant
94. Printed Name of Applicant
95. Date of Signature
(mm/dd/yyyy)
X. SUBMISSION INSTRUCTIONS
96. Check and attach the following required documents:
Copy of Designated Doctor Training Certificate(s) Copy of Designated Doctor Testing Certificate(s)
Mail the completed DWC Form-067, Designated Doctor Certification Application, and attachments to the following address
or fax to (512) 804-4207:
Texas Department of Insurance
Division of Workers’ Compensation
7551 Metro Center Drive, Suite 100
Austin, TX 78744-1645
Applicant’s Name:
Texas License #:
For TDI-DWC Use Only
