Free RESPONSE TO PETITION FOR CHANGE OF PHYSICIAN - Idaho

RESPONSE TO PETITION FOR CHANGE OF PHYSICIAN
Employer Name and Address: Surety Name and Address:

Telephone Number: Employee Name and Address:

Telephone Number: Additional Documentation to Support Decision (circle one):

No

Yes

Response to petition (circle one):

Approved

Denied

Reasons for Denial: ___________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Hearing Dates/Times Availability Next 14 Days: ___________________________________ _____________________________________________________________________________ Date: ________________ Signature: _________________________________________

Typed/Printed Name: _________________________________ Title: ______________________________________________

Original to Idaho Industrial Commission, 700 South Clearwater Lane, PO Box 83720, Boise, ID 83720-0041, or faxed to the Commission at 208-332-7558. Copy to Employee.
(Rev. 3/01/2008) Appendix 7B Response - Page 1 of 2

CERTIFICATE OF SERVICE
I hereby certify that on the ______ day of ___________, 20____, I caused to be served the Original Response to 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

I also hereby certify that on the _____ day of ____________, 20___, I caused to be served a true and correct copy of the foregoing Response to Petition for Change of Physician upon:

CLAIMANT'S NAME AND ADDRESS _________________________________________ _________________________________________ _________________________________________ via: ( ) Personal Service of Process ( ) Regular U. S. Mail

________________________________ Signature ________________________________ Print or Type Name

Response- Page 2 of 2