Free Request for Change / Opt-Out Return completed form to: American Mining Claims S... - West Virginia


File Size: 107.5 kB
Pages: 1
Date: March 19, 2008
File Format: PDF
State: West Virginia
Category: Workers Compensation
Word Count: 110 Words, 709 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.wvinsurance.gov/wc/pdf/forms/Request_for_Change_or_Opt-Out.pdf

Download Request for Change / Opt-Out Return completed form to: American Mining Claims S... ( 107.5 kB)


Preview Request for Change / Opt-Out Return completed form to: American Mining Claims S...
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