Select Service Level:  

Platinum - Complete and File DWC-32; Prepare Analysis; FOL Tracking
Gold - (For use only when claimant requests DD); Prepare Analysis; FOL Tracking
Silver - Complete and File DWC-32; FOL Tracking

Date of Request:	Saturday, September 04, 2010
Your Name:	First: Last:     (required)
Phone:
Your Email Address:	(required)

Claimant:	First: Last:    (required)
Address:	City: State:  Zip Code:    AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
DWC Number:
Date of Injury:
Carrier Name: (not a TPA name)
TPA Name (if applicable):
Claim Number:
Claimant Attorney:
Health Care Network (If Any):
Date of Statutory MMI:
Name of Employer:

Reason For Request - From Carrier's Perspective:

A.

Determine MMI

B.

Determine IR Only

C.

Determine Extent of Employee’s compensable injury.

List all compensable injuries (diagnoses, body parts and/or conditions) not in dispute:

Describe the accident or incident that caused the claimed injury:

List all disputed injuries (diagnoses, body parts and/or conditions) claimed to be a cause of or naturally resulting from the accident or incident:

D.

Determine whether the employee’s disability is a direct result of the work related

Identify non-work related injuries causing disability:

Identify dates of claimed disability:
Beginning:    
Ending:    

E.

Determine the ability of the Employee to return to work.

Identify dates of disability you want the Designated Doctor to address:

Beginning:    
Ending:    

Claimant’s pre-injury job classification:

SedimentaryLightMediumHeavyVery Heavy

F.

Determine the employee’s ability to return to work for SIBs after the 8th Qtr

(Section 408.151) - Dates of Qualifying Period:

G.

Other issues only similar to those listed

Example: Is the claimed injury consistent with the claimed mechanism of the injury (only use with compensability disputes)

Name of Treating Doctor:
Address:	City: State:  Zip Code:    AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Phone:

We have accepted as compensable an injury to the following body parts(s) /conditions only:

We specifically do not accept responsibility for the following body parts(s) /conditions:

Other concerns to forward to Designated Doctor:

DFW Metroplex file pick up:
Contact:
Paul Railey: 214/704-0066
pkr@fol.com

Return medical records to:
FOL DDR Dept.
P.O Box 13367— Austin, TX 78711
Phone: 512-435-2299 — Fax: 512-867-1749
Email: ddr@fol.com

Attach:

DWC-1
PLN-1
PLN-11
ALL BFOs
Claim File notes and Medical Payment Screens(For FOL Use Only)
Complete copy of all medical records
Any videos you wish to send to Designated Doctor

I am transmitting the support documents via:

Email to: SendTo@FOL.com
FOL Dallas Metroplex Service Representative to Retrieve
Fax to: (512) 867-1749
Overnight Mail to: FOL DDR Dept., 504 Lavaca, STE 1000 Austin, Texas 78701

504 Lavaca, STE 1000 Austin, Texas 78701 | P.O. Box Drawer, 13367 Capitol Station Austin, Texas 78711
Tel 512.477.4405 | Fax 512.867.1700 | Email fol@fol.com

© 2006 Flahive, Ogden & Latson, Attorneys at Law, P.C. For questions, comments, or site related problems notify webmaster@fol.com