The dwc 069 form is the Texas report a doctor uses to say whether you have reached maximum medical improvement (MMI). If you have, the same report gives your impairment rating. The certifying doctor fills out and files the form, not you. Even so, this one report can shape how much you are paid and for how long. That makes it worth understanding, even if you never touch the paperwork yourself.
What the Dwc 069 Form Is For
When you are hurt at work in Texas, your doctor treats you until your condition stops improving in a meaningful way. That point is called maximum medical improvement. Once you reach it, a doctor must decide how much permanent impairment you have. They express it as a whole-body percentage. That number is your impairment rating.
The dwc 069 form is the official record of those two decisions. In most cases, it is the document that ends one type of income benefit and may start another. As a result, the date of MMI and the rating percentage on this form matter a lot. They affect your income benefits, so it is normal to feel uneasy when this report shows up. Knowing what it says will help you decide calmly what to do next.
| Item | Details |
|---|---|
| Form number | DWC Form-069 |
| Form title | Report of Medical Evaluation |
| Who files | The certifying doctor (MMI and impairment rating) |
| Where filed | Texas Department of Insurance, Division of Workers’ Compensation, with copies to the parties as the rules require |
| Fee | No filing fee for the injured worker |
| Official PDF | https://www.tdi.texas.gov/forms/dwc/dwc069medrpt.pdf |
Who Files the Dwc 069 Form and When
Only a doctor who is allowed to certify MMI and assign an impairment rating can complete the dwc 069 form. Typically, this is your treating doctor. However, it may also be a designated doctor chosen by the state, or a doctor the insurance carrier sends you to. In some cases, your treating doctor refers you to another doctor who does the rating instead.
Each doctor who certifies MMI files their own report. For example, your treating doctor may say you have a 5% rating, and a designated doctor may say something different. This is common. When reports conflict, Texas rules decide which one carries more weight. A designated doctor’s report usually carries extra weight. You can still challenge it, though.
One note on the rating above: the 5% figure was only an example. It is not a typical or expected rating. Every case is different.
How to Fill It Out and Where to Send It
The doctor fills out the form, but it helps to know what it contains. First, it lists your name, claim details, and the insurance carrier. Next, the doctor states whether you have reached MMI and on what date. Then the doctor gives the impairment rating percentage. A narrative report must go with the form. That report explains how the doctor reached the rating, using the edition of the AMA Guides that Texas rules require.
Reports often get questioned or sent back for common reasons. These include:
- A missing doctor signature or date
- No narrative report attached
- An MMI date but no impairment rating
- A doctor who is not certified to assign ratings
- A rating that does not follow the required AMA Guides method
- Missing body parts or conditions that are part of the accepted claim
Generally, the doctor sends the dwc 069 form to the Division, the insurance carrier, you, and your representative if you have one. The rules on electronic versus paper filing can change, so check with the agency. You can view the official PDF at the Texas DWC numeric forms page. You can also open the form directly here: DWC Form-069 Report of Medical Evaluation (PDF).
What Happens After You File
When the dwc 069 form arrives, read every line. Check the MMI date. Check the rating. Also check whether every injured body part was evaluated. In most cases, the carrier uses the rating to calculate impairment income benefits. As a result, a low or incomplete rating can mean lower payments. If something looks wrong, you can ask for a designated doctor exam or start a formal dispute with the Division. Remember the dispute window in the deadline box above.
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You do not have to face this alone. The Texas Department of Insurance, Division of Workers’ Compensation, has an ombudsman program that helps injured workers for free. For more background, see our guide to the Texas workers comp board. You can also review Texas workers comp requirements. If your claim is still new, read how to file a Texas workers comp claim. Confirm any figure or deadline with the Division and a licensed attorney before you act.
Frequently Asked Questions
Do I have to fill out the dwc 069 form myself?
No. The certifying doctor completes and files the dwc 069 form. Your job is to read your copy carefully. Then decide whether you agree with the MMI date and the rating.
What if I disagree with my impairment rating?
You may be entitled to dispute it. Typically, this means requesting a designated doctor exam or filing a dispute with the Division. Act quickly, because the first certification can become final if you miss the window. Confirm the exact deadline with the Division and a licensed attorney.
Does reaching MMI mean my benefits stop?
Not always. Reaching MMI usually ends one type of income benefit. However, a rating above zero may lead to impairment income benefits. Many Texas claimants with serious ratings may also qualify for further benefits. Any example amounts are only illustrations, and every case is different.
Dwc 069 form: Quick Recap
If you remember one thing about dwc 069 form, make it this: the rule is set by the state (or the federal program), not by the insurer, and the official source is linked above. Every figure on this page about dwc 069 form should be confirmed with the agency before you act on it.
Questions about dwc 069 form that this page does not answer are usually answered for free by the state workers’ comp agency’s information line — and, for a disputed claim, by a licensed attorney in a first consultation.
See your state’s exact numbers
What you are owed depends on your state’s benefit caps and deadlines. Start with your state’s settlement and claim guides for the exact figures.
Sources & How to Verify
The figures on this page come from official government and industry sources. Workers’ comp benefit caps, deadlines, and rules change, so always confirm the exact figure with your state’s workers’ comp board or a licensed attorney before acting. Settlement estimates are illustrative, and every case is different.
- Your state workers’ comp board, division, or commission: the official source for your state’s exact caps, deadlines, and forms — search “[your state] workers compensation board”
- U.S. Department of Labor (OWCP): dol.gov — federal workers’ compensation overview
- NCCI: ncci.com — workers’ comp rating and benefit data
- Social Security Administration: ssa.gov — benefit-cap and SSDI offset data
- Insurance Information Institute: iii.org — neutral workers’ comp background
Content last reviewed October 2026. If you notice an outdated figure, please contact us.
Related Guides
- Texas Workers Comp Board
- How to File a Texas Workers Comp Claim
- Texas Workers Comp Requirements
- Workers Comp Settlements by State (All 50)
- Workers Comp Claims by State (All 50)
- More in This Category
- Settlements by Injury
- Benefits Explained
- Workers Comp Glossary
Informational only — not legal, medical, or financial advice. Workers Comp Explained is an independent educational resource, not a law firm, insurer, or medical or financial advisor, and this page does not provide legal, medical, or financial advice. Workers’ compensation benefits, deadlines, and rules vary by state and change over time, and settlement estimates are illustrative only. Always confirm the exact figure and any deadline with your state’s workers’ compensation board and a licensed attorney before you act.