TEXAS  WORKERS’

COMPENSATION  COMMISSION

ADVANCE NOTICE REGARDING NON-RELATED AND/OR PRE-EXISTING CONDITIONS

Texas Workers’ Compensation Commission (TWCC) will only pay for health care services that it determines to be directly and/or indirectly related to a work injury.  If TWCC determines that a particular service(s) is medically unrelated to your work injury under TWCC program standards, TWCC may deny payment of that service and treatment(s) may not be the responsibility of your workers’ compensation insurance carrier.  TWCC may also deny payment of service and treatment(s) if they determine your injury did not happen on your job.

I, ____________________________________________________________, D.O.

believe that, in your case, TWCC is likely to deny payment for:  [specific particular service(s)]

1.      _______________________________________________________________

2.      _______________________________________________________________

3.      _______________________________________________________________

4.      _______________________________________________________________

for the following reasons:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

“I have been notified by my physician that TWCC is likely to deny payment for the service(s) identified above, for the reasons stated.   If TWCC denies payment, I agree to be personally and fully responsible for payment of the above specified services if treatment is requested by me and rendered by my physician.  I have also been notified that if I claim this injury is not work related, but I later claim it to be work related, I am responsible for the payment of all services rendered by my physician, up until the point I informed the physician of the injury’s work related status.”

___________________________________________________      ____________________________

(Signature of Patient)                                                              (Date)