STATE OF COLORADO OFFICE OF ADMINISTRATIVE COURTS th 633 17 Street, Suite 1300, Denver, CO 80202 Fax: (303) 866-5909 1259 Lake Plaza Drive, Suite 210, Colo. Springs, CO 80906 Fax: (719) 576-2978 th 222 S. 6 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 Complete Section A, B, or C A. The Respondents have filed a Notice of Contest within the previous 45 days on (date) _____________________ and the claimant requests an expedited hearing on compensability and medical benefits. (Attach a copy of the Notice of Contest). Section 8-43-203(1)(a), C.R.S.; or B. There is an urgent need for prior authorization of health care services, as recommended in writing by ________________________________, an authorized treating provider, and prior authorization has been denied. (Attach a copy of the recommendation of the authorized treating provider). The claimant requests an expedited hearing. Rule 16-10, WCRP; or C. The Respondents have filed a Petition to Suspend, Modify, or Terminated Compensation on (date) _____________ and the claimant filed an objection to the Petition on (date) _______________. The Respondents request an expedited hearing. (Attach a copy of the Petition and objection). Rule 6-4, WCRP. 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) If space is available as determined by OAC, the parties have conferred and request the following date and time for this hearing: Date: Time: Request for the OAC to Set the Matter for Hearing (Rule 8(H) OACRP): If you are not represented by an attorney and would like the Office of Administrative Courts to set this case for you, please check here: American LegalNet, Inc. www.FormsWorkflow.com Signature: X Signature Street Address Print/Type Name City, State, Zip Code Attorney Registration Number Phone Number Fax Number (Optional) E-Mail Address: (Failure to provide an e-mail address may result in delay in receipt of any procedural or final order) Date Certificate of Mailing I hereby certify that I mailed or delivered the original of the Application for Hearing and Notice to Set to: Office of Administrative Courts 633 17th Street, Suite 1300 Denver, CO 80202 Office of Administrative Courts 1259 Lake Plaza Dr., Suite 210 Colorado Springs, CO 80906 And copies to all parties at the addresses shown below: Office of Administrative Courts 222 South 6th Street, Suite 414 Grand Junction, CO 81501 (A claimant must provide a copy to the employer and the insurer, or their attorney.) Claimant/Respondent or their Representative: Employer or their Representative: Other: Signature Date Mailed REV 12/07 American LegalNet, Inc. www.FormsWorkflow.com