COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Division of Workers' Compensation REQUEST FOR CHANGE OF PHYSICIAN Claimant Claimant's Telephone # Employer Date of Injury Insurance Carrier Insurance claim # WC# (if applicable) I am requesting a change of authorized treating physician/facility from (name of current physician/medical facility) to (name of requested physician/medical facility). If proposing more than one new physician/facility, a list may be attached on a separate sheet. CERTIFICATE OF SERVICE: Copies of this document were placed in the U.S. mail, hand-delivered, faxed or emailed to the following parties this day of , . Day Month Year List the name(s) and mailing address(es), fax number(s) or email address(es) of all person(s) copied: Respondents' Representative(s): By: Signature RESPONSE TO REQUEST (Check one box and return to claimant) The request to change physicians is: GRANTED: If approval is granted, write the name of the new physician/facility on the line below: DENIED CERTIFICATE OF SERVICE: or emailed to the claimant this Copies of this document were placed in the U.S. mail, hand-delivered, faxed day of , . Month Year Day List the name(s) and mailing address(es), fax number(s) or email address(es) of all person(s) copied: Claimant or Claimant's Attorney: By: WC 197 Rev 6/16 Signature American LegalNet, Inc. www.FormsWorkFlow.com