Free 11.4.4 NMAC - New Mexico

STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION

__________________________________________, Worker, v. __________________________________________, and __________________________________________, Employer/Insurer.

WCA No.:___________________________

HEALTH CARE PROVIDER DISAGREEMENT FORM REQUEST FOR CHANGE OF HEALTH CARE PROVIDER A disagreement has arisen over the selection of a health care provider. The _____Worker ______Employer is requesting a change to_________________________________________________________________. (Name of proposed health care provider) The current health care provider's provision of medical care is unreasonable because: ___________________________________________________________________________________________ ___________________________________________________________________________________________

___________________________________ Signature of filing party

1.

Worker's Name:_____________________________ SSN:______________________________________ Date of Accident:____________________________ Mailing Address:____________________________ City/State/Zip:______________________________ Phone Number:(___)_________________________

2.

Worker's Rep:_______________________ Address:____________________________ City/State/Zip:________________________ Phone Number:(___)___________________ Fax Number:(___)_____________________

3.

Employer:__________________________________ 4. Address:____________________________________ City/State/Zip:_______________________________ Phone Number:(___)__________________________ Fax Number:(___)____________________________ Employer's Rep.:_____________________________ Address:____________________________________ City/State/Zip:_______________________________ Phone Number:(___)__________________________ Fax Number:(___)____________________________

Insurer:_____________________________ Address:____________________________ City/State/Zip:________________________ Phone Number:(___)___________________ Fax Number:(___)_____________________

5.

[This form must be filed with the Clerk of the Workers' Compensation Administration]

11.4.4.9.18.2.L NMAC