W.C.C. # of pending cases: __________________________ __________________________ Providence, SC. State of Rhode Island and Providence Plantations Workers’ Compensation Court Name of Employee W.C.C. # XXX-XXSocial Security Number (last 4 digits only) - vs.- Insurance Carrier Name of Employer Insurance Carrier Address Address Request for Permission for Major Surgery The undersigned alleges as follows: The employee sustained an injury on for which major surgery is needed. Date The employer has/has not been found liable under the terms of the Workers’ Compensation Act. (If applicable, attach a copy of any agreement or decree establishing liability) A medical record or report is attached to this petition from the surgeon stating that the employee’s major surgery is necessary to cure, rehabilitate or relieve him/her from the effects of the work injury. The proposed surgery is described as follows: _____________________________________________ The employee desires such surgery and will undergo same within ________ days. Permission for surgery has been requested from the employer or its insurance carrier and has not been received. (Attach copy of such request). Wherefore the employee requests an ex-parte order granting permission for such surgery. Attorney for Employee Employee Address and phone number of attorney Address Attorney bar registration number EX-PARTE ORDER Permission for the performance of the above described major surgery by Dr. ____________________ is hereby granted provided such surgery is performed by said surgeon within ______ days from the date hereof. No liability of any kind is imposed upon the employer or its insurance carrier by this order. A copy of this order shall be mailed forthwith by the Administrator of this Court, by ordinary mail, postage prepaid to said employer with a copy to the insurance carrier. Dated this ___________day of _______________________, 20___________. ENTER: PER ORDER: _________________________________________ Judge ____________________________________ Administrator Instructions Prepare original and four copies with the appropriate attachments and file with the Office of the Administrator of the Workers’ Compensation Court, J. Joseph Garrahy Judicial Complex, One Dorrance Plaza, Providence, Rhode Island 02903-3973. Distribution: Rev 02/08 White: Original Green: Employee Yellow: Doctor Pink: Employer Gold: Insurer Carrier American LegalNet, Inc. www.FormsWorkflow.com