Please provide the specific reason(s) for the requested examination. The reason(s) must indicate how the examination will resolve a dispute or assist in the progression of the claim.
If a previous designated doctor examination has occurred for this claim, explain any change of medical condition since that examination
If approval of this request would result in TDI-DWC scheduling an examination within 60 days of a previous designation doctor examination, provide good cause as to why it is necessary to schedule this examination within 60 days.
List all injuries determined to be compensable by TDI-DWC or accepted as compensable by the insurance carrier.
