STATE OF NEW MEXICO WORKERS222 COMPENSATION ADMINISTRATION , WCA No.: Worker, v. , and , Employer/Insurer. ORDER GRANTING APPROVAL OF OUT OF STATE HEALTH CARE PROVIDER THIS MATTER having come before the Director pursuant to Section 52-4-1(P), NMSA 1978, and having reviewed the Application to Director and Affidavit of the proposed out of state health care provider (applicant), the Director FINDS; 1.The Applicant is licensed in the State of and said license is in good standing. 2.The Applicant has satisfied the Director that authorization to provide health care to the worker in thiscase will not unduly disrupt the operation of the New Mexico workers' compensation system. 3.Good cause exists to approve Applicant as an out of state health care provider.IT IS THEREFORE ORDERED as follows: 1.Subject to the provisions of Section 52-1-49, NMSA 1978, is approved as an out of state health care provider to treat worker in this workers222 compensation case. 2.As an approved out of state health care provider, issubject to the New Mexico Workers222 Compensation Act and its rules and regulations, including the health care provider fee schedule. 3.The Director retains the right to revoke, suspend, or place conditions on this approval withoutcause. 4.If this out of state health care provider222s medical license is suspended or revoked, this approvalshall be automatically revoked and effective as of the day of suspension or revocation. WCA Director Approved as to form: Signature of Worker Signature of Insurer Attorney/Adjuster 11.4.7.10 NMAC American LegalNet, Inc. www.FormsWorkFlow.com NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION OUT OF STATE HEALTH CARE PROVIDER AFFIDAVIT 1.I, being duly sworn or affirmed, state: I am licensed as a , in the State of , and my license to practice is currently in good standing; 2.I acknowledge that I have treated or intend to treat an injured worker involved in a workers222compensation claim governed by the laws of New Mexico. 3.I agree to be bound by the Workers' Compensation Act of the State of New Mexico and all Workers'Compensation Administration (WCA) rules and regulations, including provider fee schedules that establish maximum allowable payments for clinical and non-clinical services. 4.I understand that my designation as an approved health care provider for can be revoked, suspended or conditioned, by written order of the Director of the WCA, at any time, with or without cause; and 5. I understand that if my license to practice in is suspended or revoked, my designation as an approved health care provider is automatically revoked, with or without notice, by the Director of the Workers' Compensation Administration. Signature Health Care Provider 226 Printed Name Address City/State/Zip Telephone ACKNOWLEDGMENT STATE OF ) ) ss. COUNTY OF ) Subscribed and sworn or affirmed to before me this day of , 20. Notary Public My commission expires: American LegalNet, Inc. www.FormsWorkFlow.com