STATE OF COLORADO OFFICE OF ADMINISTRATIVE COURTS 1525 Sherman Street, 4th Floor, Denver, CO 80203 Fax: (303) 866-5909 1259 Lake Plaza Drive, Suite 230, Colo. Springs, CO 80906 Fax: (719) 576-2978 222 S. 6th Street, Suite 414, Grand Jct., CO 81501 Fax: (970) 248-7341 Claimant, COURT USE ONLY vs. WC NUMBER: Employer, and DATE OF INJURY: Respondent. APPLICATION FOR EXPEDITED HEARING ONE - TIME CHANGE OF AUTHORIZED TREATING PHYSICIAN An Expedited Hearing is requested pursuant to Rule 8 - 5(C), Workers222 Compensation Rules of Procedure (check all that apply): Claimant has requested a one-time change of physician (You must attach a copy of the notice.); Insurer has provided a written objection within 7 business days of the request (You must attach a copy of the written objection.); There exists a factual dispute requiring a hearing. (state below the factual dispute(s) that exist). The opposing party may file a response to this Application for Expedited Hearing within 10 days of the mailing or delivery of this Application for Expedited Hearing. Witnesses to be called at the hearing or by deposition: List names and addresses: 1. 2. 3. 4. 5. 6. (Attach additional pages if necessary) The Office of Administrative Courts will set this case for hearing and will send notice to the parties. American LegalNet, Inc. www.FormsWorkFlow.com X Signature Attorney Registration Number First Name MI Last Name: Suffix Company Address City State Zip Phone E - mail I hereby certify that I mailed or delivered true and correct copies of the APPLICATION FOR EXPEDITED HEARING ONE-TIME CHANGE OF AUTHORIZED TREATING PHYSICIAN to all parties at the addresses shown below: (A claimant must provide a copy to the employer and the insurer, or their attorney.): Party 1 First Name MI Last Name Suffix Company Address City State Zip Phone E - mail Recipient is the: Party 2 First Name MI Last Name Suffix Company Address City State Zip Phone E - mail Recipient is the: Signature of person submitting document Date served Rev 3 /15 American LegalNet, Inc. www.FormsWorkFlow.com