FO&L Designated Doctor Review

Select Service Level:  




I will attach:




I will transmit the support documents via:




Date of Request: Wednesday, July 26, 2017
Your Name: (required)
First: Last: 
Phone:  
Your Email Address: (required)  
Claimant:(required)
First: Last: 
Claimant's Phone:  
Address:
City: State: Zip Code:
 

DWC Number:  
Date of Injury:  
Carrier Name: (not a TPA name)
TPA Name: (if applicable)
Claim Number:
Claimant Attorney:
Health Care Network: (if any)
Political Subdivision: (if any)
Date of Statutory MMI:  
Name of Employer:
Name of Treating Doctor:

Address:
City: State: Zip Code:
 


Phone:
Insurance Carrier's
Bill Review Agent Name:
Bill Review Agent Address:
City: State: Zip Code:
 


Bill Review Agent Phone Number:
Bill Review Agent Fax Number:
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:

Reason For Request - From Carrier's Perspective:

A.
Are you disputing a prior certification?
B.
Are you disputing a prior IR?
C.
D.
Identify non-work related injuries causing disability:
Identify dates of claimed disability:
Beginning:  
Ending:  
E.
Identify dates of disability you want the Designated Doctor to address:

Beginning:  
Ending:  
Claimant’s pre-injury job classification:



F.
(Section 408.151) - Dates of Qualifying Period:
Quarter #:
Has there been a SIBs DD exam within the last 365 days?
State beginning & ending dates of qualifying period:
Beginning:  
Ending:  
G.
Example: Is the claimed injury consistent with the claimed mechanism of the injury (only use with compensability disputes)

Return medical records to:
FOL DDR Dept.
P.O Box 201329 Austin, TX 78720
Phone: 512-435-2294 or 512-435-2251
Fax: 512-241-3349
Email: ddr@fol.com
DFW Metroplex file pick up:
Contact:
Paul Railey: 214/704-0066
pkr@fol.com