Rev 11.4.4.12 (D) NEW MEXICO WORKERS222 COMPENSATION ADMINISTRATION NOTICE OF CHANGE OF HEALTH CARE PROVIDER A party has filed a Notice of Change of Health Care Provider in your workers222 compensation case pursuant to Section 52-1-49 of the New Mexico Workers222 Compensation Act or Section 52-3-15 of the New Mexico Occupational Disablement Law. If you are the injured worker, you must change to the health care provider named below within 10 days of the postmark or delivery date of this notice. You may object to the change by filing an 223Health Care Provider Disagreement Form224 with the Workers222 Compensation Administration within 3 days of receipt of this notice. If you do not file the Objection within 3 days, the change will be binding. If you file the Objection after 3 days, the change will remain in effect unless it is changed by the court. The party making the change is: This notice was sent to: Worker222s Name: Employer222s Name: Address: Address: Telephone No.: Telephone No.: Insurance Company: Claims Representative: Address: Telephone No.: Worker222s Attorney, if any: Employer222s Attorney, if any: Address: Address: Date of Accident: County of Accident: Type of Injury: Current health care provider: Address: Telephone No.: Signature of Person sending this Notice: Date: Your rights may be affected by your failure to respond to this notice: if you need assistance and are not represented by an attorney, contact an ombudsman of the WCA Albuquerque: (505) 841-6000 or 1 (800) 255-7965 Farmington: (505) 599-9746 or 1 (800) 568-7310 Las Cruces: (575) 524-6246 or 1 (800) 870-6826 Las Vegas: (505) 454-9251 or 1 (800) 281-7889 Hobbs: (575) 397-3425 or 1(800) 934-2450 Roswell: (575) 623-3997 or 1 (866) 311-8587 Santa Fe: (505) 476-7381 American LegalNet, Inc. www.FormsWorkFlow.com