Free GOING BACK TO WORK - New Mexico


File Size: 340.7 kB
Pages: 31
Date: April 25, 2008
File Format: PDF
State: New Mexico
Category: Workers Compensation
Author: Merilee Dannemann
Word Count: 11,481 Words, 78,384 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://workerscomp.state.nm.us/pdf/booklets/B4.pdf

Download GOING BACK TO WORK ( 340.7 kB)


Preview GOING BACK TO WORK
The Workers' Compensation Handbook For New Mexico

Medical Care in Workers' Compensation
Who decides which doctor will treat the worker for a work-related injury .............................. 3
First selection of health care provider..............................................................................................3 Notification that you have selected the health care provider .............................................................4 Second selection of Health Care Provider ........................................................................................5 Health care provider selection and change chart ..............................................................................6 Worker ­ to change health care provider.........................................................................................7 Change of health care provider at any other time ............................................................................9

Booklet B4:

Should you sign this form?.............................................................................................. 10 What kinds of doctors may treat under workers' compensation .......................................... 10

If the doctor is in another state .................................................................................................... 11 Causation .................................................................................................................................... 12 Stay at work / Return to work ...................................................................................................... 12 Maximum medical improvement (MMI) ......................................................................................... 12 Impairment rating........................................................................................................................ 12 Form Letter to Health Care Provider.............................................................................................. 13 Medical releases .......................................................................................................................... 13

Decisions for the doctor .................................................................................................. 12

Communication between the doctor and employer or claim representative .......................... 13 Will workers' compensation cover this medical care? ......................................................... 14

"Reasonable and necessary" medical care ( ................................................................................... 14 Referrals, specialists and therapists............................................................................................... 15 Caregivers ................................................................................................................................... 15 If you receive a medical or hospital bill ......................................................................................... 16 If the claim is not compensable .................................................................................................... 17 Right to lifetime medical care ....................................................................................................... 17 Independent Medical Examinations (§52-1-51) ............................................................................ 17 Periodic Examinations by previous doctor (§52-1-51(D)) .............................................................. 18 Travel expenses for medical care .................................................................................................. 18 Case management (§52-4-3) ........................................................................................................ 19 Utilization review (§52-4-2) .......................................................................................................... 19

Medical bills ................................................................................................................... 15 Special issues in medical care under workers' compensation .............................................. 17

Forms in this booklet ...................................................................................................... 21
Help from the Workers' Compensation Administration .................................................................... 29 Workers' Compensation Handbook List of Booklets ........................................................................ 30

The Workers' Compensation Handbook for New Mexico Booklet B4: Medical Care in Worker's Compensation

2007 Edition page 2

__________________________________________________________

NOTE: This booklet replaces the previous editions of BOTH Booklets B4 and C4. Booklet C4, "Resolving Health Care Provider Disputes," is discontinued.
Medical care under the workers' compensation system is a little bit different from ordinary medical care. The worker wants to receive high-quality health care. The insurer or self-insurance program must be concerned about controlling costs. In addition, everyone is concerned about how health care affects the worker's ability to go back to work. Medicine is not an exact science. In many cases there is not one "best" method of treatment or one "best" doctor for a particular injury or illness. The goal of medical care under workers' compensation should be to help the injured worker recover from the injury or disability and be able to rejoin the workforce as quickly as possible. Worker: Nobody has more power to heal your injury than you. You share responsibility for the success of your treatment. You should be involved in your treatment plan, ask questions, understand what is being done for your benefit and participate actively in your recovery. You are responsible for following the doctor's instructions, taking medication, putting genuine effort into physical therapy and exercise sessions and putting your mind to the task of becoming well again. You should also follow general good health practices during your time of recovery, such as eating and resting properly. Employer: Your role in the medical care of your injured employee is limited but critically important. It's your job to make sure your employee has clear information on the selection of health care provider ­ which, preferably, should have been done in advance as a company policy. You can act in your best interest as well as the best interest of the worker by maximizing the opportunities for the worker to stay at work or return to work quickly, by offering work options consistent with the worker's physical restrictions. You can make this easier for the worker and the doctor by providing clear and complete written information such as a job description. If the worker is back to work during the treatment and recovery period, you are responsible for implementing any temporary or long-term work restrictions so that the worker is able to keep working and the chance of re-injury is minimized.

Published by the New Mexico Workers' Compensation Administration, a state agency. Laws can change. Check for new information by calling1-866-WORKOMP or 1-866-967-5667 or look on the Internet at www.workerscomp.state.nm.us.

____________________________

The Workers' Compensation Handbook for New Mexico Booklet B4: Medical Care in Worker's Compensation

2007 Edition page 3

Who decides which doctor will treat the worker for a work-related injury (§52-1-49)?
First selection of health care provider
Before the worker goes to the doctor (except in an emergency), make sure you know who selected the health care provider. This subject was covered briefly in Booklets A2 and B1. Under the workers' compensation law (§52-1-49(B)) 1 , the employer has the right to decide either: · to select the health care provider who will treat the injured worker, or · to let the worker select the health care provider. If the employer selects first, after 60 days or more of treatment the worker will have the right to change to a different doctor (Rules, NMAC 11.4.4.11.E(1)) 2 . If the worker selects first, after 60 days or more of treatment the claim representative will have the right to require the worker to change to a different doctor (Rules, NMAC 11.4.4.11.E(1)). The 60-day period begins with the date of the first treatment or visit (except emergency treatment). Under the rules of the New Mexico Workers' Compensation Administration (WCA) (Rules, NMAC 11.4.4.11.C (2)), employers are required to instruct all their workers in advance, in writing, as a company policy. Has the employer done this? (See Booklet A2.) If the employer has not given instructions in advance, the employer should give the injured worker an instruction as soon as possible, before the worker gets any treatment except emergency. The exception for emergencies is in the Rules of the WCA, NMAC 11.4.4.11 (C(1)).

BEST PRACTICE:

It is very important to make sure the worker receives the right kind of information at the right time. If this has not been done in advance (see Booklet A2), the employer or an authorized supervisor should do this now in writing. The employer tells the worker either to go to a specific doctor or medical facility or to select his own doctor.

1 In this booklet are references to specific paragraphs of the workers' compensation law. These references are in a

standard form. §52-1-49(B) NMSA means Chapter 52, Article 1, Paragraph 49(B) of the New Mexico Statutes Annotated (NMSA).
2

In this booklet are references to the Rules of the Workers' Compensation Administration. These references are in a standard form based on the numbering system of the New Mexico Administrative Code (NMAC); for example, NMAC 11.4.4.11. This stands for Title 11, Labor and Workers' Compensation; Chapter 4, Workers' Compensation; and then the number of the section and exact paragraph.

The Workers' Compensation Handbook for New Mexico Booklet B4: Medical Care in Worker's Compensation

2007 Edition page 4

The worker should keep a copy of the written instruction. The employer or supervisor should also keep a copy, plus a written note indicating when and by whom this information was given to the worker. Almost all disputes about health care provider selection happen because the communication was not clear at the beginning. By communicating clearly at the beginning, and documenting your communication in writing, you can prevent a dispute, so that the claim and the worker's medical care are easier for all parties.

Worker:
If your employer has told you to select your own doctor, do not ask for a recommendation on a doctor. It's up to you. You might want to take your time and do some checking before you select a doctor. Contact the doctor's office and make sure the doctor is willing to take your case. If you are selecting your own doctor and planning to go to your regular family doctor, before you go, get a copy of Booklet B8 and take it with you. That is a booklet written for doctors who are not familiar with workers' compensation.

Notification that you have selected the health care provider
Worker:
This is not a form, but a letter that you might receive from the claim representative. If you receive a letter telling you that you have already made the first selection of health care provider, and you think you did not make a selection, call an ombudsman. EMPLOYER QUESTIONS: Q: A worker at my business had an accident and went to the emergency room in our community. The emergency medical staff gave the employee the name of a doctor for follow-up care. The employee went to that doctor. So I don't think either one of us actually selected the health care provider. What difference does it make? A: Under the Rules of the WCA, you (the employer) selected the health care provider because you did not give your employee any instruction. This is important only if there is a disagreement later on about the medical care the worker is receiving. If the worker and the claim representative are satisfied with the worker's care from this doctor, the selection of health care provider will not be an issue. But if the care is not satisfactory to one party or the other, the party who did not make the first selection is entitled to choose a different provider after 60 days. If you did not notify the worker in writing, you are presumed to have made the first selection, and the worker has the right to make the second selection. Suppose your claim representative is not satisfied with the health care this worker is receiving, but the worker does not want to change. If the worker made the first selection, the claim representative will have a right to the second selection after 60 days. If you made the first selection, the claim representative will have no such right. WORKER QUESTIONS Q. The claims representative sent me to a doctor after my injury. I did not think he was doing a very good job so I went to my own doctor. Now the claims representative says the insurance company will not pay the bills. Can they do that? A. Yes. If you go to your own doctor without telling anybody, after you have been instructed to go to a doctor by a claims representative, you are responsible for your own bills.

The Workers' Compensation Handbook for New Mexico Booklet B4: Medical Care in Worker's Compensation

2007 Edition page 5

Q. I did not use my option to change doctors after 60 days of care. I have been seeing the doctor chosen by my employer for 90 days, but now I want to change. Can I still use my automatic right? A. Yes. The law provides for one change by automatic right, on or after 60 days of care by the first doctor. If you don't use your right at 60 days, you may use it later. Q: I want to go to my regular primary care doctor, but my doctor says he does not treat patients under workers' compensation. I don't know of any other doctor that I would like to see. What should I do? A: Show your doctor Booklet B8. Booklet B8 explains the options for the doctor. If your doctor takes the case as the authorized provider and sends you to another doctor as a referral, your doctor retains control of your medical care and can review the treatment for you. Q. My employer didn't tell me anything. I just went to my own doctor because I didn't know what else to do. Is that OK? A. Yes, it is OK. Make sure your doctor knows that this is a workers' compensation claim and that the doctor should bill your insurer or self-insurance program, not your health insurance. The claim representative might tell you after 60 days that you will have to change to another doctor, but under the rules of WCA, if the employer has failed to tell you anything, you might not have to change. See the WCA Rules, NMAC 11.4.4.11 (C)(2) (b) and (c). Q. I tried to report my work injury, but the employer said it was not covered by workers' compensation and the medical bills ended up on my group health insurance. What should I do? A. You should never agree to make a claim on your group health insurance for a work-related injury. You could end up in a dispute with both your health insurance carrier and your workers' compensation insurer. Contact an ombudsman at the WCA to help you straighten the situation out. Q. I hurt my back at work and have been getting medical treatment. Then I was involved in a car accident and it made my back injury worse. Who pays for my back injury now? A. This could be a complicated situation. The workers' compensation insurer is not responsible for the cost of a new injury, but it is still responsible for your previous injury. The insurance companies should be able to work out an agreement on dividing the costs, while you get the treatment you need. This question shows why it is good to keep up your auto insurance and health insurance, even while you are receiving workers' compensation benefits.

Second selection of Health Care Provider (§52-1-49(C))
If the employer selected the first health care provider, the worker has the right to change to a different doctor after 60 days of treatment with the first doctor. If the worker selected the first health care provider, the claim representative has the right to require the worker to change to a different doctor after 60 days. The 60 days are counted as calendar days beginning with the date of the first appointment (not including emergency treatment).

The Workers' Compensation Handbook for New Mexico Booklet B4: Medical Care in Worker's Compensation

2007 Edition page 6

Health care provider selection and change chart
Initial selection of a health care provider for the injured worker was explained in Booklet B1. This chart reviews the summary of the initial selection and shows the second selection process.
1. The employer is responsible for communicating with workers. 2. Employer should provide instructions IN ADVANCE in writing by establishing a policy that applies to all employees. Either the employer tells workers that employer is selecting the health care provider, or the employer tells workers to select their own health care provider. 3. If employer has not provided any instruction in advance, employer should provide an instruction as soon as possible, BEFORE any non-emergency health care. IF EMPLOYER SELECTS FIRST Employer instructs worker to use a specific health care provider. Worker must be treated by this health care provider (and other providers referred by the treating provider) for 60 days. SECOND SELECTION BY WORKER 4. After the initial 60-day period, the worker will have the right to change to a different health care provider. Worker sends Notice of Change of Health Care Provider to claim representative. The Notice may be sent on Day 50 or later. IF WORKER SELECTS FIRST Employer instructs worker to select a health care provider of the worker's own choosing. Worker will be treated by this health care provider (and other providers referred by the treating provider) for 60 days. SECOND SELECTION BY CLAIM REPRESENTATIVE 4. After the initial 60-day period, the claim representative will have the right to require the worker to change to a different health care provider. Claim representative sends Notice of Change of Health Care Provider to worker. The Notice may be sent on Day 50 or later.

5. Ten days after filing the notice, if the claim representative has not objected, the worker may start treatment with the new health care provider. The new provider will be the authorized treating provider for the rest of the claim.

5. Ten days after receiving the notice, if the worker has not objected, the worker must make an appointment with the new health care provider. The new provider will be the authorized treating provider for the rest of the claim. The claim representative will not pay medical bills for further treatment by first provider.

IF THERE IS AN OBJECTION TO THE CHANGE

The right to change is automatic. The party who objects has the burden of proof to show that the change will result in medical care that is not reasonable or that the party filing the Notice of Change is not entitled to the Automatic Right to Second Selection. 6. If the worker wants to object to this 6. If the claim representative wants to change, the worker must file objection object to this change, the claim within 3 days of receiving the Notice of representative must file objection within 3 Change. A hearing before a workers' days of receiving the Notice of Change. A compensation judge will be scheduled and hearing before a workers' compensation held within 7 days of the filing of the judge will be scheduled and held within 7 objection. days of the filing of the objection.

The Workers' Compensation Handbook for New Mexico Booklet B4: Medical Care in Worker's Compensation

2007 Edition page 7

Worker ­ to change health care provider (NMAC 11.4.4.11(E))
If your employer selected the first health care provider, and you would like to change to a different doctor, you have the right to make this change. Here are the steps to follow: 1. First, contact the office of the doctor you would like to select and make sure that doctor will take your case. If this doctor does not regularly treat patients under New Mexico workers' compensation, you might wish to give the doctor's office a copy of Booklet B8 ("Quick Facts for Health Care Providers"). 2. Fill out the Notice of Change of Health Care Provider form; or, if you prefer, you can write a letter including all the information in the form. A blank form is in this booklet. You can also find forms on the WCA web site or obtain a form from any office of the WCA. 3. Contact a WCA ombudsman if you would like help with the Notice of Change procedure (unless you have a lawyer). 4. You do not have to provide any reason for changing. However, you can be challenged by the claim representative if you select a doctor whose care might not be "reasonable" for the type of injury you have. 5. Mail or deliver the form to your claim representative. If you mail, it is a good idea to use certified mail with return receipt requested so that you will have a record that the form was received. If you deliver it in person, ask for a receipt. 6. Ten days after the form is received by the claim representative, if you have not received a written objection, you may start treatment with the new health care provider. 7. Your new health care provider should be aware that your insurer or self-insurance program will cover ONLY treatment for the work-related injury; only treatment that is "reasonable and necessary;" and payment will be limited by the WCA medical fee schedule. 8. If the claim representative objects to your change, do not start treatment. You will receive information from the WCA about a special hearing to resolve this issue. The hearing will be scheduled within 7 days.

If the claim representative sends you a Notice of Change
If you selected the first health care provider, then some time after 50 days of treatment, you might receive a Notice of Change from the claim representative. Ten days after you receive this notice, your workers' compensation claim will no longer pay the medical bills for the doctor who has been treating you. You can accept this change or you can respond by filing an objection ­ but if you want to object, you must act very quickly. The objection must be filed within 3 days after you receive the notice. Call an ombudsman if you want help.

The Workers' Compensation Handbook for New Mexico Booklet B4: Medical Care in Worker's Compensation

2007 Edition page 8

If you don't object to this notice ­ what to do next
1. Contact the office of the health care provider named on the form and make an appointment. 2. If you have any appointments with the doctor who has been treating you, any therapy appointments or any other medical activity based on instructions from this doctor, if they are 10 days or more in the future, contact the providers and cancel those appointments. You can explain why.

If you want to object to this notice
Reasons to file an objection might be: · You do not believe that you made the first selection. If you are correct, the claim representative does not have the right to require you to change providers. · You think the proposed treatment is not reasonable for your condition. If your only reason for objecting is that you like your current doctor and don't want to change, the law is not in your favor. Under the law, the claim representative has an automatic right to require you to change. You can still file the objection, but a judge would probably not decide in your favor. If you do not have a lawyer, you can call an ombudsman for help. If you file an objection, a hearing will be scheduled before a workers' compensation judge to decide which doctor should be treating you. To file the objection, follow these steps: 1. Fill out the Objection to Notice of Change Form. A blank form is in this booklet. You can also find forms on the WCA web site or obtain a form from any office of the WCA. 2. Mail, fax, or deliver the form to your claim representative and to the WCA. You can deliver the form in person to any office of the WCA. If you mail it, the mailing address is Workers' Compensation Administration, P.O. Box 27198, Albuquerque, New Mexico 87125-7198. It's a good idea to use certified mail with return receipt requested. The fax number for the WCA Clerk of the Court is (505) 841-6060. If you fax, telephone the Clerk of the Court to make sure your faxed objection was received. 3. The WCA will send you a notice of a hearing on your objection, scheduled within the next seven days. 4. You should be prepared to go to the hearing and explain your reasons. If you do not have a lawyer, a WCA ombudsman can give you information about this process, but the ombudsman does not represent you and will not help you at your hearing. .

The Workers' Compensation Handbook for New Mexico Booklet B4: Medical Care in Worker's Compensation

2007 Edition page 9

Change of health care provider at any other time
(§52-1-49(E))
Either party can ask for a change of health care provider at any time -- before or after a second selection has been made. There will be a hearing before a workers' compensation judge. The party who is asking for the change must show that the injured worker's medical treatment is not reasonable, and that the requested change will result in treatment that is reasonable. (Since it's easiest to make a change at the point of second selection, it would be unusual to use this procedure before that time.) The party who wants the change must file a Request for Change of Health Care Provider with the WCA Clerk of the Court (WCA Mandatory Forms 11 NMAC 4.4.9.18.2L). You can find the forms on the WCA web site or you may obtain it from any office of the WCA . A hearing will be scheduled within 7 days. A worker who does not have a lawyer and wants to make a change may call an ombudsman for information and help filling out the forms.

Worker:
If you are being treated by a doctor selected by your claim representative, and you don't like your medical treatment, discuss it with your claims representative before you file a case in court. You might find that the two of you can agree, and then you will save yourself the trouble and expense of a court hearing. If you cannot reach agreement and want to have a hearing in court, you may wish to hire a lawyer to help you with your case. See Booklet C1 before you hire a lawyer for any matter related to workers' compensation. If your claims representative files a Request for Change of Health Care Provider, and you want to oppose the request, you should talk to an ombudsman for help unless you have a lawyer. The ombudsman cannot represent you in court or provide legal advice, but can provide general information and help you fill out the forms. If you receive a Request for Change of Health Care Provider, you will automatically have a chance for a hearing in court. The insurer or self-insurance program will continue to be responsible for your medical bills until the hearing, when a judge will decide. Call an ombudsman for help, unless you have a lawyer. The "Request for Change" is different from the "Notice of Change." With the "Request for Change" procedure, the "burden of proof" is on the party who is making the request. That means whoever is making the request will have to show a judge that the current medical treatment is not reasonable.

The Workers' Compensation Handbook for New Mexico Booklet B4: Medical Care in Worker's Compensation

2007 Edition page 10

Should you sign this form?
Medical release form Worker:
You will probably be asked to sign a medical release form. A medical release form allows the doctor to share information from your medical records with the claims representative. The claims representative needs this information to pay medical bills. Doctors, hospitals, and other providers usually have their own forms that they may ask you to sign. It is your decision whether or not to sign these forms. For purposes of processing your workers' compensation claim, there is one medical release form you must sign if asked. It is the official medical release of the WCA. The title of the form is "Worker's Authorization for Disclosure of Protected Health Information for Workers' Compensation Purposes (HIPAA Compliant"). There is a copy of this form in the back of this book. (Note: this form used to have a space for a witness signature. This is no longer required as of 2007. If you are using an older form, you can ignore the witness signature.) If you think someone is pressuring you to sign any other form, and you have questions, call an ombudsman. If your doctor has any questions about this, you can show this book to your doctor or ask your doctor to call an ombudsman.

What kinds of doctors may treat under workers' compensation (§52-4-1)?
Workers can go to a number of different kinds of health care providers for treatment under workers' compensation, not just physicians and hospitals. The health care provider selected to treat a worker should be the right type of specialist for the worker's type of injury. Under New Mexico workers' compensation law, all of the following professions are recognized as health care providers, as long as they are licensed in New Mexico: · physician (MD), · osteopathic physician (DO), · chiropractor (DC), · dentist, · optometrist, · podiatrist, · physician assistant, · certified nurse practitioner, · physical therapist, · occupational therapist, · doctor of Oriental medicine,

The Workers' Compensation Handbook for New Mexico Booklet B4: Medical Care in Worker's Compensation

2007 Edition page 11

· · · · ·

psychologist, certified nurse-midwife, hospital, athletic trainer, 3 and any other person or facility that provides health-related services in the health care industry, as approved by the Director of the WCA (§52-4-1).

Not all health care providers have the same standing under law. For example, an impairment rating can be given only by a medical doctor (MD), osteopathic physician (DO) or chiropractor (DC) (§52-1-24.1 and §52.4.1; NMAC 11.4.7.7.JJ). Some types of providers may be required by law to practice under the supervision of a physician or with instructions from a physician. These restrictions would appear in the licensing laws for those professions.

If the doctor is in another state (NMAC 11.4.7.9.I)
For some workplaces, especially near the New Mexico state borders, the most convenient medical facilities are located in another state. Sometimes this can be a problem, but often it is not. Many physicians in cities near the New Mexico border are familiar with New Mexico workers' compensation. A doctor in another state can be considered an authorized provider if: · this is an emergency, OR · the doctor applies to the WCA for approval, OR · the insurer or self-insurance program acknowledges the doctor's status by paying a bill; OR · the doctor is licensed in New Mexico as well as the other state. If the insurer or self-insurance program makes any payment for this claim, the doctor is assumed to be approved, and the application process is not necessary. The application materials for the out-of-state health care provider are available on the WCA web site or through the Office of the General Counsel. The doctor's office can contact any office of the WCA for help. See the list of offices near the back of this booklet.

3

Licensed athletic trainers were added to the statute in 2007, House Bill 88.

The Workers' Compensation Handbook for New Mexico Booklet B4: Medical Care in Worker's Compensation

2007 Edition page 12

Decisions for the doctor
The doctor in a workers' compensation case does more than just treat the injured worker. The doctor is responsible for a number of decisions that are very important to the worker and the claim. The major decisions are: · · · · Causation: Whether the worker's condition was causally related to a work-related accident or occupational disease. Stay at work or return to work: When the worker can go back to work, and work restrictions, if any. Maximum medical improvement: When the worker has fully recovered, or has recovered as much as can be expected. Impairment: Whether the worker has a permanent physical impairment, and, if so, what the impairment rating is.

To review those four major types of decisions:

Causation (§52-1-28)
The doctor must give a medical opinion as to whether the worker's injury was causally related to work. This is clear in many cases where there was an accident and the injury is obviously the result, but sometimes it can be complicated. For example, sometimes it is not easy to tell what caused a back injury or a repetitive motion injury. In this case, the doctor's opinion becomes especially important.

Stay at work / Return to work
The doctor decides when it is medically safe for the worker to return to work. If the worker cannot do his regular job, but the employer is able to offer alternative choices, the doctor makes the decision whether the alternative work is medically safe. To make this decision, the doctor will need information about the worker's workplace and job. Whether the worker can go back to work depends on both the injury and the worker's job. It is usually best for the worker to go back to work as soon as it is medically safe to do so. See Booklet B3 for more about Return to Work. See the Stay at Work / Return to Work Program Guide for recommendations for the employer, worker and doctor.

Maximum medical improvement (MMI) (§52-1-24.1)
MMI is the time when the doctor decides the worker is fully recovered, or is recovered as much as he is going to be. This is a very important decision, as it means a change from temporary total disability benefits (TTD) to permanent partial disability benefits (PPD) or no benefits. See Booklets B2 and B3.

Impairment rating (§52-1-24)
An impairment rating is a number, based on the seriousness of the injury. Impairment ratings are determined using a technical guidebook called the American Medical Association

The Workers' Compensation Handbook for New Mexico Booklet B4: Medical Care in Worker's Compensation

2007 Edition page 13

Guides to the Evaluation of Permanent Physical Impairment, or the AMA Guides. If the worker is going to get PPD benefits, the impairment rating is necessary to determine how much those benefits will be. See Booklet B2.

Communication between the doctor and employer or claim representative
For the claim process to go smoothly and for the worker to have the best chance of a prompt and successful return to work, it is necessary for both the employer and the claim representative to have information from the doctor. However, the worker's privacy is protected by restrictions on communication between the doctor and the employer or claim representative. A 1992 ruling from the New Mexico Court of Appeals (Hanson v. Church's Fried Chicken) provides that the worker or the worker's attorney has the right to be present at any conversation that takes place between the health care provider and any representative of the employer (including the employer, a manager, claim representative, case manager, etc.). For this reason, some types of communication are generally done in writing, with copies sent to the worker or the worker's attorney. If the worker gives permission, communication may be less restrictive. However, coercion or pressure should never be used to obtain this permission.

Form Letter to Health Care Provider
A WCA form called the Form Letter to Health Care Provider is often used as a way of providing standardized reports on the worker's progress. It is to be filled out by the doctor on request. The doctor can be paid for this service. A copy of the Form Letter (2007 version) is in the back of this booklet. The most current version is available on the WCA web site and from all offices of the WCA. When a complaint has been filed with the WCA, the Form Letter is required and must be sent to the WCA. In other situations, the claim representative may ask the health care provider to fill out the Form Letter from time to time. These copies are between the claim representative and the health care provider only. The worker may have copies if the worker requests them.

Medical releases
The worker is required to sign the WCA medical release form as a condition of receiving workers' compensation benefits. This release form is legally titled "Worker's Authorization for Disclosure of Protected Health Information for Workers' Compensation Purposes (HIPAA Compliant)." A copy is in the back of this booklet. The form is also available on the WCA web site and from all WCA offices. This form authorizes the doctor to provide the claim representative with written medical reports and other written communication. The worker has the right to receive copies of all written communications if the worker wishes.

The Workers' Compensation Handbook for New Mexico Booklet B4: Medical Care in Worker's Compensation

2007 Edition page 14

If the worker chooses to sign a more permissive release, the doctor may converse with the employer or claims representative about such subjects as the worker's ability to return to work. The worker should never be coerced to sign such a release. If the worker has given permission, it's best for the worker to be informed about such conversations. If the worker has an attorney, the attorney should be informed also. If, in the doctor's opinion, any conversation with the employer or claims representative seems to be coercive or to interfere with medical treatment, the doctor should end the conversation immediately and document what happened.

Worker:

You are not required to sign any release concerning your medical information except the WCA authorization. If the claim representative asks you to sign a release permitting more extensive communication, you do not have to sign it. Call an ombudsman if you need help. Many doctors' offices have their own standard forms, including release forms. The doctor might require you to sign a different release form as a condition of accepting you as a patient. If you are concerned about this, call an ombudsman.

Will workers' compensation cover this medical care?
All costs of health care service are covered when: · the service is for a work-related injury or occupational illness; · the service is with an authorized health care provider; · the service provided is reasonable and necessary; · if required by the WCA (Rules, NMAC 11.4.7.14), the service has been approved by the medical review program. Under these conditions, the health care provider may not bill the worker for any balances unpaid by the insurance carrier. Health care services are not covered if: · the service is with an unauthorized health care provider; · the service is for a condition outside of the work-related injury or occupational illness; · the service is determined not to be reasonable and necessary; · the worker's injury or illness is determined not to be work-related, either by agreement or by determination of the workers' compensation court. Under these conditions, the worker is responsible for the costs of the services. If the worker has health insurance, the health insurance may pay for services for conditions outside the work-related injury or illness.

"Reasonable and necessary" medical care (§52-1-49(A))
The workers' compensation law (§52-1-49) requires the employer to provide the worker with timely, reasonable and necessary health care services from a health care provider, to continue as long as treatment is necessary.

The Workers' Compensation Handbook for New Mexico Booklet B4: Medical Care in Worker's Compensation

2007 Edition page 15

"Reasonable and necessary" is the key phrase. The insurer or self-insurance program is not required to pay for every possible treatment. Sometimes what is "reasonable and necessary" can be a matter of judgment. Workers' compensation claims adjusters generally want injured workers to recover and be able to return to work as quickly as possible. Many insurers agree that it's cost-effective to support a rapid recovery and encourage the use of medical resources in the early weeks following an injury, believing this can speed recovery and return to work, and ultimately will cost less.

Referrals, specialists and therapists
The doctor who is the authorized treating provider can refer the worker to other doctors (such as specialists), for related services such as physical therapy and for diagnostic services when needed. These referrals do are not considered a change of health care provider. The law does not require pre-approval from the claim representative for these referrals. (Exceptions include anything covered under the WCA utilization review program and certain procedures and examinations specified in the Rules of the WCA, NMAC 11.4.7.9.B). But physicians' offices usually ask for pre-approval, to avoid billing problems later.

Caregivers
A caregiver is someone, such as a home health care aide, not a medical professional, whose services may be needed in some cases. Care by a caregiver is covered when it is needed. Contact the claims representative if you believe a caregiver is needed.

Medical bills
Worker: The treatment you receive for your work-related injury should not be billed to your regular group health insurance. Make sure your doctor knows this is an on-the-job injury, and tell the doctor the name of your employer's insurer or self-insurance program, so the bill is sent to the proper party. When you fill out forms at medical offices, there is usually a question on the form asking whether the injury was work-related. If you believe it was, say so on the form. Answer the question honestly to the best of your ability. The doctor should not put any other health care services on the same bill as the worker's compensation claim. If you get other health care services while you are being treated for your injury, ask your doctor's office staff to send a separate bill for those services, to your regular health insurance or to you personally. The workers' compensation insurer or self-insurance program is not responsible for services that are not related to your work-related injury or illness.

The Workers' Compensation Handbook for New Mexico Booklet B4: Medical Care in Worker's Compensation

2007 Edition page 16

Employer:
Do not pay directly for medical treatment for your employee (unless you are an approved individual self-insured employer). The insurer or self-insurance program has the right to manage medical care under the claim. Make sure the bills are sent to the insurer or selfinsurance program. If you have a policy with a high deductible, the insurer should pay the medical bills, and you will reimburse the insurer later.

If you receive a medical or hospital bill
Worker:
Don't panic! If the bill is for your authorized work-related medical care, you will not have to pay it. Contact your claim representative. Some medical office administrators don't know that the patient is not responsible for any payment under workers' compensation and might bill you without knowing the law. Other doctors' offices may have a billing system that automatically sends you a copy of the bill, even though it has been sent to your insurer or self-insurance program. By law, the health care provider is not permitted to demand payment from you for any covered services that were provided for a work-related injury or illness. All the bills are to be paid by the insurer or self-insurance program. The insurer or self-insurance program is required to limit its payment according to fee guidelines established by law and the rules of the WCA (§52-4-5 NMSA). As a result, the doctor may receive less money than the amount on the bill. If the doctor has billed more than the amount allowed by the WCA, the doctor will have to accept the smaller amount of payment. The doctor cannot force you to pay the difference. If this becomes a problem, you can call an ombudsman. Any disagreement over the amount of a bill for authorized services is a matter between the doctor and the claims representative. It should not involve you. If the health care provider has a question about this, the provider may want to get a copy of the book published by the WCA for health care providers. This book is called The Health Care Provider's Guide to New Mexico Workers' Compensation. It is available on the WCA web site and from all offices of the WCA. If you have received medical, hospital or other health care services that are not related to your workers' compensation covered injury, these services should not be listed on the same bill as your covered treatment. If they appear on the same bill by mistake, you (or your health insurance) are responsible for the portion of the payment that is not covered by workers' compensation. A doctor in another state is not bound by the laws of New Mexico. If the doctor is not authorized, you could be responsible for bills that you should not have to pay. That is one reason why it is in your interest to make sure any out-of-state doctor is authorized.

The Workers' Compensation Handbook for New Mexico Booklet B4: Medical Care in Worker's Compensation

2007 Edition page 17

If the claim is not compensable
If it is determined that you have no right to any workers' compensation benefits, you or your health insurance plan is responsible for all your medical bills. See Booklet B1.

Special issues in medical care under workers' compensation
Right to lifetime medical care
The injured worker is entitled to medical care for the injury for the rest of his life, if required by the medical condition that resulted from the injury. The insurer or self-insurance program will be responsible for paying the authorized health care provider for reasonable and necessary medical care as long as that care is needed. The right to lifetime medical care is found in §52-5-12(A), which is the section of the law regulating lump sum payments. Under this section of the law, the insurer or self-insurance program may not close out the worker's right to future medical benefits with a lump sum payment. If medical care is no longer needed for this injury, the insurer or self-insurance program will no longer be responsible for paying for medical care.

Worker:
If you recover from your injury, and after a period of time you have new medical needs that you believe are from the injury, you might have to prove to the insurer or self-insurance program that your new medical needs are related to this injury. It is possible that your new medical problems could be the result of a new injury or the normal wear and tear of everyday living. If you need information about how to work this out with your claim representative, you can call an ombudsman unless you have a lawyer.

Best practice -- worker:

There are some types of injuries ­ certain back injuries, for example ­ that medical professionals know might cause health problems in the future. It's a good idea to talk to your doctor about the future of your medical condition. If you are considering a lump sum settlement, remember that if you accept a lump sum, your medical care will still be covered, but you will have no right to indemnity benefits for future needs.

Independent Medical Examinations (§52-1-51)
An Independent Medical Examination (IME) is a medical examination by a doctor who has not treated the worker. Some IMEs are performed by a group of doctors including different specialists. The purpose of an IME is not to provide treatment but to get an evaluation and

The Workers' Compensation Handbook for New Mexico Booklet B4: Medical Care in Worker's Compensation

2007 Edition page 18

medical opinion. Either the worker or the claims representative may request an IME if there is a dispute between the parties regarding any medical issue. To be set in accordance with the Workers´ Compensation Act, the IME must be by agreement of both parties or by order of the WCA. If the worker and the claim representative cannot agree on a doctor to perform the IME, they can have a hearing with a workers' compensation judge, who will select the doctor

The Workers' Compensation Handbook for New Mexico Booklet B4: Medical Care in Worker's Compensation

2007 Edition page 19

· · ·

actual cost of a ticket on any public transportation such as a bus or airplane; actual cost of meals, up to a maximum amount per day; if the travel takes two hours or more each way, the cost of overnight lodging, up to a maximum amount per day.

If you have to travel for medical care, contact your claim representative before the travel. Some companies have special arrangements with certain hotel or motel chains and prefer you to stay there. Also ask the claim representative or contact an ombudsman for the current maximum amount allowed for meals and lodging. Keep exact records of your travel expenses. Keep all receipts. You might want to get a small notebook just for this purpose.

Best practice: Worker

Case management (§52-4-3)
A case manager is someone who coordinates the health care services provided to an injured or disabled worker. Usually the case manager is a registered nurse. Generally, case managers are used only when the injury is quite serious or communication issues exist. A case manager may be helpful in several ways. The case manager can support the worker's recovery and assist the health care provider, for example, by helping to ensure that the injured worker keeps appointments and follows up with recommended activities. The case manager can also work with the employer to help identify opportunities for the worker to return to work. A case manager may be assigned to the worker either by the payer or the WCA. WCA- assigned case manager: The law requires the WCA to implement a case management program. This program has changed from time to time and may change again through the WCA rules revision process. As of this publication date (2007), a case manager can be assigned to the worker by the WCA when requested of any party, if approved by the WCA Director. The case managers work on contract to the WCA. A WCA assigned case manager may report to the WCA but not to the payer. (NMAC 11.4.7.14.A.1). Payer-assigned case manager: The claim representative may assign a case manager. The worker and the health care provider may cooperate with the case manager, but they are not required to provide more information to a case manager than they already have to provide to the claim representative.

Utilization review (§52-4-2)
Utilization review means checking the use of certain medical services to ensure that they are provided only when needed. The New Mexico workers' compensation law requires the WCA to have a utilization review program.

The Workers' Compensation Handbook for New Mexico Booklet B4: Medical Care in Worker's Compensation

2007 Edition page 20

As of 2007, the only requirement of this program is authorization for all in-patient hospital admissions (Rules of the WCA, NMAC 11.4.7.14(B)). The health care provider or hospital ­ not the worker -- is responsible for contacting the WCA to obtain this authorization. This must be done in advance unless the admission is for an emergency. This program has changed from time to time and is subject to change through the WCA rules revision process. Check with your claims representative for current utilization review requirements.

The Workers' Compensation Handbook for New Mexico

-- Medical Care #B4

FORMS

Forms in this booklet
This booklet contains copies of forms that are used in matters related to health care provider services. Please note that these forms may be revised from time to time. Check on the WCA web site for forms that might be more up-to-date. The forms include: Worker's Authorization for Disclosure of Protected Health Information for Workers' Compensation Purposes (HIPAA Compliant)
This form is to be signed by the worker and given to the claim representative. The claim representative will provide copies to all doctors who treat this worker. It authorizes the doctors to send medical records to the claim representative.

Form Letter to Health Care Provider
This form is used to request information from the health care provider when the claim representative needs an update on the worker's condition. Use of the form is required, and a copy of the doctor's response must be provided to the WCA, when a complaint has been filed.

Notice of Change of Health Care Provider
This form may be used by the worker to change to a different doctor when the employer selected the first health care provider, or may be used by the claim representative to require the worker to change to a different doctor when the worker selected first.

Objection to Notice of Change of Health Care Provider
This form is used to file an objection to the Notice of Change. It must be sent within 3 days of the date the Notice of Change was received.

Request for Change of Health Care Provider
This form is used to request a change of health care provider at a time other than the automatic right to change.

The Workers' Compensation Handbook for New Mexico

-- Medical Care #B4

FORMS

WORKER'S AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR WORKERS' COMPENSATION PURPOSES (HIPAA COMPLIANT) I, (Print Worker's Name) hereby authorize the health care

provider (HCP) - (the name of HCP is optional and not required for release of medical information) (Print Health Care Provider's Name) Of my health information as described in this authorization. 1. INFORMATION Date of Injury: Phone: Phone: WCA No. SSN: the use or disclosure

Date of Birth: Address: Worker's representative, if any: Address: 2. RELEASE

I authorize the Health Care Provider (HCP) or any member or employee of its office or association who has examined or treated me, as well as any hospital or treatment facility in which I have been a patient, to disclose and release complete and legible copies of any and all information concerning my physical or psychiatric condition, care and treatment, to my employer, , and /or its

insurance carrier, , and/or their attorneys, and/or duly authorized representatives of the New Mexico Workers' Compensation Administration and its current medical cost containment contractor or their duly authorized agents. Copies of all documentation released pursuant to this authorization shall be sent to the agency requesting the information and to me or my representative as listed above. 3. I understand the following information will be released pursuant to a work-related/occupational injury or illness/workers' compensation claim: medical reports; clinical notes; nurses' notes; patient's history of injury; subjective and objective complaints; x-rays; test results; interpretation of x-rays or other tests (including a copy of the report); diagnosis and prognosis; hospital bills; bills for services the HCP has rendered; payments received; and any other relevant and material information in the HCP's possession. This Authorization also includes, if applicable, any hospital operational logs, emergency logs, tissues committee reports, psychiatric reports and records, physical therapy records, and all outpatient records. This release may also be used to request a Form Letter to HCP as approved by the Workers' Compensation Administration. I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law. CONDITIONS 4. I understand the purpose of this request is to determine the proper level of workers' compensation benefits and may include information regarding any of the following: to determine my occupational injury or illness status; to determine my eligibility for workers' compensation benefits; to determine my current and future medical status after occupational injury; to determine my current medical status and/or return-to-work capability. 5. Right to revoke: I understand I have the right to revoke this authorization at any time by notifying the company named in Paragraphs 1 and 2. I understand that the revocation is only effective after it is received and logged by that company and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation. I further understand that my revocation of this authorization may affect my ability to receive occupational injury or workers' compensation benefits governed by this revocation.

11.4.4 NMAC

Rev. 2007

The Workers' Compensation Handbook for New Mexico

-- Medical Care #B4

FORMS

6. I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law. 7. I understand that information to be released pursuant to a work-related/occupational injury or illness/workers' compensation claim may also be released to WCA and its current medical cost containment contractor or their duly authorized agents. 8. I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records. 9. A photostatic or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed. 10. This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted. 11. I understand I am entitled to a copy of this authorization and to any records provided hereunder. I am requesting a copy of this authorization Yes NO - If Yes, I have received a copy (initial). I understand this authorization will expire within six (6) months of the date I signed it, unless I revoke it earlier, pursuant to Paragraph 5.

Signature of Employee:

Date

Personal Representative Section: If a personal representative executes this form, that representative warrants that he or she has authorization to sign this form on the basis of (print detailed basis for representation):

Signature of Personal Representative:

Date:

11.4.4 NMAC

Rev. 2007

The Workers' Compensation Handbook for New Mexico

-- Medical Care #B4

FORMS

STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION
FORM LETTER TO HEALTH CARE PROVIDER
TO: HEALTH CARE PROVIDER ______________________________________________ ______________________________________________ ______________________________________________ Worker:________________________________________ DOB:____ /____/____ WCA No.:____________ SSN: ___/___/___

RE:

Attached is a release of medical information by the Worker/Patient. The information requested in this letter is necessary to evaluate the Worker's legal claims. By promptly completing these forms, you speed the process of evaluation, including whether medical bills should be paid by the insurance carrier. Please answer all questions which you believe to be pertinent. Your answers must be based upon reasonable medical probability. 1. 2. 3. Who referred Worker to you for treatment?____________________________________________ Date of Worker's most recent visit or treatment: _______________________________________ What is your diagnosis of the condition(s) for which you have treated the Worker? _______________________________________________________________________________ _______________________________________________________________________________ In your opinion, are the conditions or complaints for which you have treated the Worker causally related to an on-the-job injury? Yes___ No___ Date of Injury:_____________________ Is the Worker suffering from a disease that, in your opinion, is related to employment? Yes___ No___ Date of occurrence:_______ Indicate the period of time the Worker has been unable to work:_____________________________ Is Worker able to return to work? Yes_____ If yes, same job? _____ Different job? _____ Any restrictions?___________________________________________________________________ No_____ If no, when do you anticipate a return to work?___________________________________ Has the Worker reached the date after which further recovery from, or lasting improvement to, an injury can no longer be reasonably anticipated (MMI)? Yes_____ Date of MMI:_________________________________________________________ No______ Anticipated date of MMI ________________________________________________ If the Worker has reached MMI, please indicate your opinion as to the percentage of the Worker's anatomical or functional abnormality existing after the date of MMI: a) Percentage of impairment, if any:________________________________________________ b) Whole body or body part:______________________________________________________ c) Indicate which edition of AMA Guides used:_______________________________________ d) AMA page numbers __________________________________________________________ Has a Physical Capacities Assessment or Functional Capacity Evaluation been performed? Yes___ No___ Was the evaluation performed by a licensed physical therapist or occupational therapist? Yes___ No___ Can the Worker: a) Lift over 50 pounds occasionally or up to 50 pounds frequently? Yes___ No___ b) Lift up to 50 pounds occasionally or up to 25 pounds frequently? Yes___ No___ c) Lift up to 20 pounds occasionally or up to ten pounds frequently, and either walk or stand to a significant degree, or sit most of the time with a degree of pushing and pulling arm or leg controls or both? Yes___ No___ d) Lift up to ten pounds occasionally or up to five pounds frequently, and occasionally walk or stand to carry out job duties? Yes ____ No___ Comments:_____________________________________________________________________ Please describe any other restrictions on Worker's activities not covered above: _______________________________________________________________________________ _______________________________________________________________________________

4.

5. 6. 7.

8.

9.

10.

11.

12.

The Workers' Compensation Handbook for New Mexico

-- Medical Care #B4

FORMS

13. Other remarks:_________________________________________________________________________ ____________________________________________________________________________________________________ ________________________________________________________________________ 14. Have you made any referrals to other health care providers, hospitals or institutions? Yes___ No___ If yes, provide the name: __________________________________________________________________ 15. Please attach a copy of any unpaid bills. The maximum allowable fee for this form is $45.00. The fee for copying of medical records and reports for the first ten (10) pages is $10.00, and $.20 cents for each additional page. I hereby swear and affirm that the foregoing responses or opinions are true and correct, to a reasonable medical probability, on pain and penalty of perjury.

Date:___________________ __________________________________ Signature of Physician __________________________________ Printed Name of Physician ____________________________________ Address ____________________________________ City/State/Zip (___)_______________________________ Telephone Number

SEND COMPLETED FORM TO: Workers' Compensation Administration, P.O. Box 27198, Albuquerque, NM 87125-7198

The Workers' Compensation Handbook for New Mexico

-- Medical Care #B4

FORMS

NOTICE OF CHANGE OF HEALTH CARE PROVIDER UNDER AUTOMATIC RIGHT OF SECOND SELECTION NEW MEXICO WORKERS' COMPENSATION LAW
This notice is sent by one party in a New Mexico workers' compensation case to the other party in the case. The party sending the notice claims to have the automatic right to change health care provider, under Section 52-1-49 of the Workers' Compensation Law or Section 52-3-15 of the Occupational Disease Disablement Law of New Mexico. The party sending this notice hereby notifies the other party that the health care provider whose services are covered under the workers' compensation claim will be changed, effective 10 days after the date this form is postmarked or delivered to the other party. The party receiving this notice may object to the change, by filing a "Health Care Provider Disagreement Form" with the court of the New Mexico Workers' Compensation Administration. If the form is not filed within 3 days, this change is binding upon the party who received the notice. If a Health Care Provider Disagreement Form is filed at a later date, the change specified in this notice remains in effect until decision of the court. The party sending this notice is: ____________________________________________________________________________ This notice is sent to: ______________________________________________________________________________________

Worker's Name: ___________________________________ Employer's Name: ___________________________________ Worker's Address: _________________________________ Employer's Address: _________________________________

Worker's Telephone Number: (____ )_______ - _________ Employer's Telephone Number: (____ )_______ - _________ Insurance Company: _______________________________ Claims Representative: ________________________________ Address: ________________________________________________________Telephone Number: (____)_______ - _________ Worker's Attorney, if any: ___________________________ Employer's Attorney, if any: ___________________________ Address: ________________________________________ Date of Accident: __________________________________ Address: ___________________________________________ County of Accident: __________________________________

Type of injury: __________________________________________________________________________________________ Name of doctor/provider now providing treatment: _____________________________________________________________ Address of doctor: ________________________________________________Telephone Number: (____ )_______ - _________ Name of new doctor/provider: ______________________________________________________________________________ (Must be licensed in New Mexico): Telephone Number: (____ )_______ - _________

Address of new doctor: ____________________________________________________________________________________

Signature of person sending this notice: __________________________________________ Date: _______________________

TO THE PERSON RECEIVING THIS NOTICE: Your rights may be affected by your failure to respond to this notice. If you need assistance and are not represented by an attorney, contact an Ombudsman of the Workers' Compensation Administration. Call the HELP Line at: 1-866-WORKOMP / 1-866-967-5667 WORKER: If you have received this notice, you are required to change from your current doctor to the new doctor named above in 10 days, unless you respond to this notice within 3 days. HCP Optional Form, Rule 11.4.4.11.E(2).

The Workers' Compensation Handbook for New Mexico

-- Medical Care #B4

FORMS

STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION _________________________________________ , Worker vs. _________________________________________ and Employer _________________________________________ Insurer HEALTH CARE PROVIDER DISAGREEMENT FORM OBJECTION TO NOTICE OF CHANGE
The Notice of Change was completed by: Worker Employer on (date) _________________. 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: ____________________________________ 3. Employer: ____________________________________ Address: _____________________________________ City/State/Zip: _____________________________________ Phone Number: ____________________________________ Fax Number: ____________________________________ 5. Employer's Rep: ___________________________________ Address: ____________________________________ City/State/Zip: ____________________________________ Phone Number: ___________________________________ Fax Number: ____________________________________ 2. Worker's Rep: _________________________________________ Address: _________________________________________ City/State/Zip: __________________________________________ Phone Number: __________________________________________ Fax Number: __________________________________________ 4. Insurer: __________________________________________ Address: ___________________________________________ City/State/Zip: ___________________________________________ Phone Number: ___________________________________________ Fax Number: ___________________________________________

WCA No. ______________________

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

WCA Mandatory Forms 11 NMAC 4.4.9.18.2L

The Workers' Compensation Handbook for New Mexico

-- Medical Care #B4

FORMS

STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION _________________________________________ , Worker vs. _________________________________________ and Employer _________________________________________ Insurer 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

WCA No. ______________________

__________________________________________________________. The current health care provider's provision of medical care (Name of proposed health care provider) is unreasonable because: _________________________________________________________________________________________________________________ ________________________________________________ Signature of Filing Party 1. Worker's name:___________________________________ SSN: __________________________________ Date of Accident: ____________________________________ Mailing Address: ____________________________________ City/State/Zip: _____________________________________ Phone Number: _____________________________________ 3. Employer: ____________________________________ Address: _____________________________________ City/State/Zip: _____________________________________ Phone Number: ____________________________________ Fax Number: ____________________________________ 5. Employer's Rep: ___________________________________ Address: ____________________________________ City/State/Zip: ____________________________________ Phone Number: ___________________________________ Fax Number: ____________________________________ 2. Worker's Rep: _________________________________________ Address: _________________________________________ City/State/Zip: __________________________________________ Phone Number: __________________________________________ Fax Number: __________________________________________ 4. Insurer: __________________________________________ Address: ___________________________________________ City/State/Zip: ___________________________________________ Phone Number: ___________________________________________ Fax Number: ___________________________________________

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

WCA Mandatory Forms 11 NMAC 4.4.9.18.2L

The Workers' Compensation Handbook for New Mexico

-- Medical Care #B4

FORMS

Help from the Workers' Compensation Administration
(See the list of offices and telephone numbers at the end of this booklet)

Personal contact
Contact an ombudsman. You can telephone or come in person to any WCA office around the state. (If you want to come in person, it's best to make an appointment.) Some ombudsmen speak Spanish. Use a local phone number or a FREE toll-free phone number. An ombudsman will talk to you informally and give you information about your rights.

WCA publications

You can get publications from any office of the WCA. Go to an office or telephone to request publications by mail. process in a relatively simple, easy to understand way, telling you your rights and responsibilities. It contains forms that you can use to keep track of your claims.

Workbook for Injured Workers is a book written just for workers. It explains the claims

Employer's Guide to New Mexico Workers' Compensation is written just for employers and gives information addressed to the employer in a simplified format. The Workers' Compensation Handbook for New Mexico (the booklets in this series) are more detailed, containing more information than the Workbook for Injured Workers.
The Health Care Provider Guide is a detailed guidebook for the doctor and the doctor's office staff. A brief summary of health care provider information is in Booklet B8 of The Workers' Compensation Handbook for New Mexico.

Stay at Work/Return to Work Program Guidebook is a guide for employers, workers and doctors about the benefits of keeping injured workers at work or getting them back to work as soon as medically possible This guidebook includes a sample early Return to Work program and helpful forms to develop a tailored and effective Stay at Work/Return to Work Program. Some WCA publications are available in Spanish. Some publications are available online from the WCA web site.

WCA web site

www.workerscomp.state.nm.us

Look under Booklets for copies of the booklets you can read, download and print. Look under Workers for other information that might be useful for you. You can print out copies of the forms from the Workbook for Injured Workers so you will have extra copies. Look under News and Announcements for any new changes that might affect you.

The Workers' Compensation Handbook for New Mexico

-- Medical Care #B4

FORMS

Workers' Compensation Handbook List of Booklets
This list shows new titles and numbering system that will be in effect when the 2007 revision is completed. Some booklets are eliminated and others are renumbered. There are some changes from the pre-2007 editions of the booklets.
To get the information you need: Contact any office of the Workers' Compensation Administration for printed copies OR All booklets can be downloaded from the Workers' Compensation Administration web site at www.workerscomp.state.nm.us

Booklet Booklet Booklet Booklet Booklet Booklet

A1(E) A1(S) A2 A3 A4 A5

Workers' Compensation Quick Facts- English Compensación A Los Trabajadores Informes Básicos ( Spanish) Setting Up a Workers' Compensation Program The Workers' Compensation Coverage Guide for Employers and Insurance Agents Uninsured Employers' Fund Workers' Compensation Personnel Assessment Fee (WC-1)

Booklet B1 What to Do after an Accident Booklet B2 Benefits for Workers While They Cannot Work Booklet B3 Going Back to Work Booklet B4 Medical Care in Workers' Compensation (B5 and B6 will be discontinued) Booklet B7 Información del sistema compensativo para los empleados (Spanish) Booklet B8 Quick Facts for Health Care Providers Booklet C1 When you need help with a workers' compensation claim Booklet C2 What to Do In Response to "Bad Acts" (C3 through 5 will be discontinued) Booklet D1 Booklet D2 Annual Safety Inspections How to Develop a Safety Program (published by the Advisory Council on Workers' Compensation and Occupational Disease Disablement)

(On the web site, look under Employers)
E3 E4

Guide to Completing and Filing Paper Copy for Employers' First Report of Injury or Illness (Form E1.2) and Notice of Benefit Payment (Form E6.2) EDI Guide to Completing the Employers' First Report of Injury or Illness (Form E1.2) and Notice of Benefit Payment (Form E6.2) -- limited to certified electronic filers

Other publications

Health Care Provider Guide to New Mexico Workers' Compensation Guidebook for Employers in New Mexico (English and Spanish) Workbook for Injured Workers (English and Spanish) The Stay at Work/Return to Work Program Guide
Wcamjd 9/07

The Workers' Compensation Handbook for New Mexico

-- Medical Care #B4

FORMS

NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION
STATE HEADQUARTERS Mailing Address: Workers' Compensation Administration PO Box 27198, Albuquerque NM 87125 Location: 2410 Centre Avenue SE (near Yale-Gibson intersection) In-state toll-free phone: 1-800-255-7965 Local phone 841-6000 REGIONAL OFFICES: Southeastern regional office at Lovington: 100 West Central, Lovington, NM 88260 Telephone: 575-396-3437 In-state toll-free phone: 1-800-934-2450 Southwestern regional office at Las Cruces: 1120 Commerce Drive, Suite B-1, Las Cruces, NM 88011 Telephone: 575-524-6246 In-state toll-free phone: 1-800-870-6826 Northwestern regional office at Farmington: 3535 East 30th Street, Farmington, NM 87401 Telephone: 505-599-9746 In-state toll-free phone: 1-800-568-7310 Northeastern regional office at Las Vegas : 2515-2 Ridge Runner Road, Las Vegas NM 87701 Moving in 2008 to: 32 New Mexico 65, Las Vegas NM 87701 Telephone: 505-454-9251 In-state toll-free phone: 1-800-281-7889 Roswell Office: Penn Plaza Bldg., 400 N. Pennsylvania Ave., Ste. 425, Roswell NM 88201 Telephone: 575-623-3781 In-state toll-free phone: 1-866-311-8587 Santa Fe Office: 810 West San Mateo, Suite A-2, Santa Fe, NM 87505 Telephone: 505-476-7381 Internet web site address: http://www.workerscomp.state.nm.us/ HELP & HOTLINE: 1-866-WORKOMP / 1-866-967-5667

mjdwca 1/08