Free Form A - Application for accelerated docket for change of physician rev 07-05.pub - Oklahoma

FORM A
Send original to Workers' Compensation Court and 1 copy to Each Opposing Party/Counsel In re Claim of: Full Name of Claimant (Injured Employee) Claimant's Social Security Number Name of Employer (Respondent)

WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OKLAHOMA 73105-4918

THIS SPACE FOR COURT USE ONLY

FILE NO. Date of Injury

Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured

CLAIMANT'S APPLICATION FOR CHANGE OF PHYSICIAN AND REQUEST FOR HEARING
[For use ONLY if the worker is NOT subject to a Certified Workplace Medical Plan (CWMP).] Pursuant to 85 O.S., Section 14(G), CLAIMANT herein respectfully requests that the above captioned matter be set for hearing on the issue of change of physician. In support of this application, claimant states as follows: 1. 2. 3. 4. Claimant is not subject to a certified workplace medical plan. A change of physician is sought for treatment of claimant's _____________________________________(state injured body part). The name of claimant's current treating physician is _______________________________________________________________. Claimant presents to the employer/respondent the following list of three (3) physicians qualified to treat the claimant's injured body part for which a change of physician is sought: (1)________________________________(2) ________________________ (3) _____________________________________________. The agreed venue for this Application is: Oklahoma City Tulsa Other__________________________ (specify)

5.

I declare under penalty of perjury that I have examined all statements contained herein, and to the best of my knowledge and belief, they are true, correct and complete. ANY PERSON WHO COMMITS WORKERS' COMPENSATION FRAUD, UPON CONVICTION, SHALL BE GUILTY OF A FELONY. Signed this _____ day of _______________________, ________.
Signature of Claimant Claimant's Address (Number and Street) City Claimant's Telephone Number State Zip Print or Type Name of Attorney for Claimant, if any Signature of Attorney for Claimant Claimant's Attorney's Address (Number and Street) City Claimant's Attorney's Telephone Number State Zip OBA #

CERTIFICATE OF SERVICE
This is to certify that on this __________ day of ______________________, __________, the foregoing instrument was mailed, postage prepaid, to:
Opposing Party/Counsel Address (Number and Street) City State Zip Opposing Party/Counsel Address (Number and Street) City State Zip

2/06

_________________________________________________ (Signature of Claimant or Claimant's Attorney, if any.)