Notice Of Change Of Health Care Provider Form. This is a New Mexico form and can be use in Workers Compensation.
Tags: Notice Of Change Of Health Care Provider, New Mexico Workers Compensation,
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. NOTICE OF CHANGE OF HEALTH CARE PROVIDER : Index No. UNDER AUTOMATIC RIGHT OF SECOND SELECTION : NEW MEXICO WORKERS’ COMPENSATION LAW Calendar No. This notice is sent by one party in a New Mexico workers’ compensation case :to the other party in the SUBPOENA JUDICIAL case. The party sending the Plaintiff(s) notice claims to have the automatic right to change health care provider, under Section 52-1-49 of the Workers’ Compensation Law or Section 52-3-15 of the Occupational Disease Disablement Law of New Mexico. -against: The party sending this notice hereby notifies the other party that the health care provider whose services are covered under the : workers’compensation claim will be changed, effective 10 days after the date this form is postmarked or delivered to the other party. The party receiving this notice may object to the change, by filing a Health Care Provider Disagreement Form” with the : court of the New Mexico Workers’ Compensation Administration. If the form is not filed within 3 days, this change is binding upon the party who received the notice. If a Health Care Provider Disagreement Form is filed at a later date, the change specified Defendant(s) : in this.notice .remains.in .effect until. decision . . . . . court. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . of the . . . . The party sending this notice is: This notice is sent to: THE PEOPLE OF THE STATE OF NEW YORK Workers Name: Employer's Name: TO Worker’ Address: s Worker’ Telephone Number: s Employer’ Address: s ( ) Employer’ Telephone Number: s - GREETINGS: Insurance Company: - Telephone Number: Date of Accident: ) Claims Representative: Address: ( County of Accident: ) WE COMMAND YOU, that all business and excuses being laid aside, you( and each of you attend before , the Attorney, if at the Employer’ Court if any: Worker'sHonorable any: s Attorney, located at County of Address: in room , on the day of , 20 ,Address: o'clock in the at noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Type of injury: Name of doctor/provider now providing treatment: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Address of doctor: whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Telephone Number: ( ) the party on result of your failure to Name of new doctor/provider: comply. (Must be licensed in New Mexico): Address of new Witness, Honorable doctor: Court in County, Signature of person sending this notice: Telephone Number: ( ) - , one of the Justices of the day of , 20 Date: TO THE PERSON RECEIVING THIS NOTICE: Your rights may be affected by your failure to respond to this notice. If you (Attorney must sign above and type name below) need assistance and are not represented by an attorney, contact an Ombudsman of the Workers’Compensation Administration, at one of the following telephone numbers: Albuquerque: (505) 841-6000 or 1 (800) 255-7965 Farmington: (505) 599-9746 or 1 (800) 568-7310 Attorney(s) for Las Cruces: (505) 524-6246 or 1 (800) 870-6826 Las Vegas: (505) 454-9251 or 1 (800) 281-7889 Lovington: (505) 396-3437 or 1 (800) 934-2450 WORKER: If you have received this notice, you are required to change from your current doctor to the new doctor named above in 10 days, unless you respond to this notice within 3 days. Office and P.O. Address HCP Optional Form, Rule 184.108.40.206.2 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Workers’Compensation Handbook American LegalNet, Inc. www.USCourtForms.com