STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION
__________________________________________, Worker, v. __________________________________________, and __________________________________________, Employer/Insurer.
WCA No.:___________________________
HEALTH CARE PROVIDER DISAGREEMENT FORM OBJECTION TO NOTICE OF CHANGE The Notice of Change was completed by:_____Worker_____Employer on the ____________, 20___. The Notice of Change is objected to by the _____Worker_____Employer. A health care provider hearing is requested on this Objection to Notice of Change 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