Health Care Provider Disagreement Form - Request For Change Of Health Care Provider
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Health Care Provider Disagreement Form - Request For Change Of Health Care Provider Form. This is a New Mexico form and can be use in Workers Compensation.
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Tags: Health Care Provider Disagreement Form - Request For Change Of Health Care Provider, New Mexico Workers Compensation,
STATE OF NEW MEXICO
WORKERS’ COMPENSATION ADMINISTRATION
__________________________________________,
Worker,
v.
__________________________________________, and
WCA No.:___________________________
__________________________________________,
Employer/Insurer.
HEALTH CARE PROVIDER DISAGREEMENT FORM
REQUEST FOR CHANGE OF HEALTH CARE PROVIDER
A disagreement has arisen over the selection of a health care provider. The _____Worker ______Employer is
requesting a change to_________________________________________________________________.
(Name of proposed health care provider)
The current health care provider’s provision of medical care is unreasonable because:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________
Signature of filing party
1.
Worker’s Name:_____________________________
SSN:______________________________________
Date of Accident:____________________________
Mailing Address:____________________________
City/State/Zip:______________________________
Phone Number:(___)_________________________
2.
Worker’s Rep:_______________________
Address:____________________________
City/State/Zip:________________________
Phone Number:(___)___________________
Fax Number:(___)_____________________
3.
Employer:__________________________________ 4.
Address:____________________________________
City/State/Zip:_______________________________
Phone Number:(___)__________________________
Fax Number:(___)____________________________
Insurer:_____________________________
Address:____________________________
City/State/Zip:________________________
Phone Number:(___)___________________
Fax Number:(___)_____________________
5.
Employer’s Rep.:_____________________________
Address:____________________________________
City/State/Zip:_______________________________
Phone Number:(___)__________________________
Fax Number:(___)____________________________
[This form must be filed with the Clerk of
the Workers’ Compensation Administration]
11.4.4.9.18.2.L NMAC
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