DWC Form-022, Request for a required medical examination (RME) 2026

1. Click ‘Get Form’ to open DWC Form-022 in the editor.
2. Begin with Section 1: Claim Information. Fill in the employee's name, Social Security number (last four digits), phone number, and address. Ensure you also include the date of injury and any representative's details if applicable.
3. Proceed to Part 2: Insurance Carrier Information. Enter the insurance carrier's name, address, adjuster's details, and confirm if medical benefits are from a certified health care network.
4. In Section 2: Examination Information, provide the doctor's name, license number, contact information, and appointment details. Specify if the examination location is over 75 miles from the employee’s address.
5. Complete Section 3: Purpose of Examination by checking relevant issues previously addressed or appropriateness of health care. Ensure to document any previous examination dates and agreements regarding attendance.
6. Finally, certify your request in Section 4 by signing and dating the form. Make sure all information is accurate before submitting.

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