Free D-52 - Nevada

State of Nevada Department of Business & Industry

Division of Industrial Relations
Workers' Compensation Section ALTERNATIVE CHOICE OF PHYSICIAN or CHIROPRACTOR (NRS 616C.090)
A list of the Panel of Treating Physicians or Chiropractors, or those health care providers, with whom your insurer has contracted, can be obtained from your insurer or third-party administrator upon written request. Your insurer or third-party administrator has 3 working days to provide you the list pursuant to NAC 616C.030. If within the first 90 days after the date of injury, you are not satisfied with the first treating physician or chiropractor and Your insurer has entered into a contract with a managed care organization or with health care providers; you must select an alternative physician or chiropractor according to the terms of the contract. This selection may be made without the prior approval of the insurer. If after choosing your physician or chiropractor, you move to a county not serviced by the contracted managed care organization or health care providers and the insurer deems it impractical for you to continue treating with the physician or chiropractor, you must choose a treating physician or chiropractor who has agreed to the to the terms of the contract unless the insurer authorizes you to choose another physician or chiropractor; or Your insurer has not entered into a contract with an organization for managed care, or with health care providers, you may select an alternative physician or chiropractor from the Panel of Treating Physicians and Chiropractors.

NOTICE: Any further changes in your treating physician or chiropractor must be in writing and approved by the insurer. If, at any time, you are dissatisfied with a physician or chiropractor selected by yourself, the insurer, managed care organization, or health care provider, a change may be made by submitting a written request to the insurer indicating the name of the alternate physician or chiropractor. The insurer shall approve or deny this request within ten (10) days after receipt of the written request or it shall be deemed approved. You will receive written notification if the insurer denies this request which will include the reason for the denial and appeal rights.

D-52 (Rev. 07/09)