Date of Request

    Your Name (First Last)*


    Your Email*

    Claimant Name (First Last)*

    Claimant's Phone

    Claimant's Address

    DWC No.

    Date of Injury

    Carrier Name (Not TPA)

    TPA Name (if applicable)

    Claim Number*

    Claimant Attorney (if applicable)

    Treating Doctor (First Last)

    Network Status (include name of network)

    Please list what injuries you have accepted on this claim

    Previous DD date

    Stat MMI date

    Please check the issues you would like the DD to address:

    Maximum Medical Improvement (MMI)Impairment Rating (IR)Extent of InjuryDisabilityReturn to WorkOther Similar Issues


    The purpose of the Law Office of Ricky D. Green website is to provide general information about our law firm and information about legal matters that may be of interest to you. The website and the materials included herein are not intended to provide legal advice. Any information provided on this website is not intended and should not be taken as legal advice or as legal opinion. The use of the information provided in this website should not be taken as creating an attorney-client relationship between the Law Office of Ricky D. Green and the reader or user of the information. While we intend to make every effort to ensure that all information on the site is accurate, we do not make any representation or assume liability for the content, accuracy, timeliness, completeness or other aspect of the information provided.  Calculations provided are for informational purposes only and are based on the Texas Labor Code and Division Rules.  The Law Office of Ricky D. Green assumes no liability for usage of the calculators.