RMD-003 (Revised 5/06)
OKLAHOMA WORKERS' COMPENSATION COURT
1915 NORTH STILES g OKLAHOMA CITY, OK 73105-4918 g (405) 522-8640
R E Q U E S T
F O R
C O U R T
F O R M S
THE FOLLOWING COURT FORMS ARE AVAILABLE FREE OF CHARGE FROM THE WORKERS' COMPENSATION COURT. They also may be downloaded from the Court's web site at www.owcc.state.ok.us. TO ORDER, COMPLETE THIS FORM AND SEND IT TO THE WORKERS' COMPENSATION COURT AT THE ABOVE ADDRESS, ATTENTION: FORM REQUEST. YOU MUST INCLUDE A SELF-ADDRESSED, STAMPED ENVELOPE LARGE ENOUGH TO ACCOMMODATE THE QUANTITY OF FORMS ORDERED. CALCULATE POSTAGE USING THE CHART BELOW. ALL FORMS EXCEPT FORM 1A
Quantity 1-4 5-10 11-16 17-22 23-29 30-35 36-41 42-47 48-53 54-59 60-65 66-71 72-77 78-100
Postage
44¢ 1 44¢
61¢ 2-5 61¢
.78 6-8 .78
$1.22 9-11 $1.22
$1.39 12-14 $1.39
$1.56 15-17 $1.56
$1.73 18-20 $1.73
$1.90 21-23 $1.90
$2.07 24-25 $2.07
$2.24 26-27 $2.24
$2.41 28-30 $2.41
$2.58 31-33 $2.58
$2.75 34-36 $2.75
Ship bulk rate 37 and above Ship bulk rate
FORM 1A
FORM NO. A
Quantity Postage
DESCRIPTION Claimant's Application for Change of Physician and Request for Hearing. (Rev. 2/06)
QUANTITY
FORM NO. 10M
DESCRIPTION Response to Request for Payment of Charges for Medical or Rehabilitation Services. (Rev. 2/06)
QUANTITY
A - Order 1A
Order for Change of Treating Physician.
(Rev. 5/06)
13 14
Request for Prehearing Conference.
(Rev. 2/06)
Oklahoma Workers' Compensation Notice and Instruction to Employers and Employees (Rev. 7/05)
Agreement Between Employer and Employee as to Fact with Relation to an Injury and Payment of Compensation. (For injuries occurring before 7/1/05) (Rev.2/06) Disclosure Statement. (Rev. 2/06)
1A
A Viso E Instrucciones Para Todas Los Empleados Y Empleadores Sombre La Compensacion Para Los Trabajadores De Oklahoma. (Rev. 8/05) Employer's Application for Permission to Carry Its Own Risk Without Insurance. (Three Page Form) (Rev. 12/99) Compromise Settlement. (Rev. 2/06)
17
1B
18
Request For Administrative Review of Disputed Medical Charges. (Rev. 2/06) Request for Payment of Charges for Medical or Rehabilitation Services/ Notice of Appeal of Administrative Order (Rev. 2/06) Proof of Loss For Spouse and Children (Rev. 2/06)
1X
19
CCS 2
Certificate To Settle By Compromise Settlement (Rev. 7/05) Employers' First Notice of Injury. (Rev. 2/06)
20 26
Memorandum of Agreement as to Fact with Relation to an injury and Payment of Disability Compensation. (For injuries occurring after 6/30/05) (Rev. 2/06) Application and Order for Leave to Withdraw as (Rev. 2/06) Attorney of Record. Pauper's Affidavit. (Rev. 2/06)
3
Employees' First Notice of Accidental injury and Claim for (Rev. 2/06) Compensation. Claimant's First Notice of Death and Claim for Compensation. (Rev. 2/06) Employee's First Notice of Occupational Disease and Claim for Compensation. (Rev. 2/06) Employee's Claim for Benefits for Combined Disabilities Against the Last Employer. (Rev. 2/06) Employee's Claim for Benefits From Multiple Injury Trust Fund. (Rev. 2/06) Treating Physician's Report and Notice of Treatment. (Rev. 2/06) Treating Physician's Progress Report. (Rev. 2/06)
93
3A
99
3B
100
Claimant's Application and Order for Dismissal. (Rev. 2/06) Application for Physicians Seeking Appointment as an Independent Medical Examiner (Rev. 2/06) Application for Medical Case Manager (Rev. 2/06)
3E
463
3F
626
4
862
Application for Vocational Rehabilitation Evaluator. (Rev. 11/01) Joint Petition. Certificate of Joint Petition. (Rev. 2/06) (Rev. 2/06)
4A 5 7 9 10
JP CJP
Physician's Report on Release and Restrictions. (Rev.4/06) Designation of Service Agent. Motion to Set for Trial (Rev. 2/06) (Rev. 2/06)
Answer and Pretrial Stipulation Offered by Respondent. (Rev. 2/06) Respondent's Response to Claimant's FORM-A Application For Change Of Physician (Rev. 2/06)
10A