Free Form A - order for change of physician_FINAL rev 07-05.pub - Oklahoma

FORM-A ORDER

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

THIS SPACE FOR COURT USE ONLY

In re Claim of:
Full Name of Claimant (Injured Employee) Claimant's Social Security Number Name of Employer (Respondent) Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured FILE NO. Date of Injury

ORDER FOR CHANGE OF TREATING PHYSICIAN
[For use ONLY if the worker is NOT subject to a Certified Workplace Medical Plan (CWMP).] NOW on this _______ day of ________________________, ________, the Workers' Compensation Court, being well and fully advised in the premises, FINDS AND ORDERS AS FOLLOWS:

THAT the claimant is not covered by a Certified Workplace Medical Plan.

THAT the parties

have

have not

agreed to a treating physician pursuant to 85 O.S., Section 14(G).

IT IS THEREFORE ORDERED, that Dr____________________________________________ is designated as the treating physician pursuant to 85 O.S., Section 14(G) regarding injury to claimant's_______________________________________________, (state injured body part).

BY ORDER OF _____________________________________________________ WORKERS' COMPENSATION COURT JUDGE

A copy hereof was mailed, postage prepaid, by United States regular mail on this file-stamped date to all attorneys of record and to unrepresented parties, as follows:
Claimant/Counsel Address (Number and Street) City Rev 05/06 State Zip Employer-Respondent/Counsel Address (Number and Street) City State Zip