Request for Change / Opt-Out
Return completed form to: American Mining Claims Service P. O. Box 660988 Birmingham, AL 35266-0988
Change of Physician
1. Claimant's Name:
Opt-Out of Provider Network
2. Claim Number:
3. Social Security Number:
4. Date of Injury:
I am requesting to:
Change physicians to another network provider
Seek treatment with an out-of-network physician
I am presently being treated by:
I am requesting to change to:
Address of requested physician (Street, City, State, Zip):
My reason for changing physicians or seeking treatment out of network:
I have checked with the requested physician to see if he / she will take me as a patient:
Yes
No
Claimant's Signature
Date