Free PETITION FOR CHANGE OF PHYSICIAN - Idaho

PETITION FOR CHANGE OF PHYSICIAN
Employee Name and Address: Employer Name and Address:

Telephone Number: Social Security Number:

Current Physician and Address:

Surety Name and Address (if known):

Requested Physician and Address:

Additional Information or Documentation Attached (Circle One): No Yes

Date of Injury/Disease: General Information:

__________________________________________________________ __________________________________________________________

__________________________________________________________________________________ Medical Treatment to Date: __________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Reason for Change: ________________________________________________________________

__________________________________________________________________________________ Hearing Date/Time Availability Next 30 Days: ___________________________________________ Date: ____________ Signature:__________________________________________________ Typed/Printed Name: ________________________________________ ORIGINAL TO EMPLOYER OR SURETY Copy to Idaho Industrial Commission, 700 South Clearwater Lane, PO Box 83720, Boise, ID 83720-0041, or fax to 208-332-7558.
(Rev. 3/01/2008) Appendix 7A Petition - Page 1 of 2

CERTIFICATE OF SERVICE
I hereby certify that on the _____ day of ____________, 20___, I caused to be served the Original Petition for Change of Physician upon either the following Employer or its Surety: EMPLOYER'S NAME AND ADDRESS
________________________________ ________________________________ ________________________________ OR

SURETY'S NAME AND ADDRESS
_________________________________ _________________________________ _________________________________

via:
( ) Personal Service of Process ( ) Regular U. S. Mail

via:
( ) Personal Service of Process ( ) Regular U.S. Mail

I also hereby certify that on the _____ day of ____________, 20___, I caused to be served a true and correct copy of the foregoing Petition for Change of Physician upon: Idaho Industrial Commission 700 South Clearwater Lane Post Office Box 83720 Boise, Idaho 83720-0041 via: ( ) Personal Service of Process ( ) Regular U. S. Mail ( ) Faxed to 208-332-7558

____________________________________ Signature ____________________________________ Typed or Printed Name

Petition - Page 2 of 2