Notice to Change Physician of Record The physician selected must be BWC certified or the injured worker will be responsible for payment. Date of injury Claim number Phone number ( ) State Nine-digit ZIP code Part I Injured worker's name Address City Instructions for the injured worker ·Please complete all of Part I of the form. ·Sign in the space provided, and submit all copies to your managed care organization (MCO) to record your change of physician. Please change my physician of record for the above listed claim as follows: From physician Address City To physician Address City Reason for change Physician moved Physician no longer practicing I moved Physician is not a BWC-certified provider Other, please explain: State State Provider number Phone number ( ) Nine-digit ZIP code Provider number Phone number ( ) Nine-digit ZIP code Physician terminated patient-provider relationship Please explain: Dissatisfied with physician's treatment Please explain: Have you been treated by the new physician for the condition(s) allowed in your claim? Injured worker's signature Yes No If yes give date of first treatment _________________________________ Date Part II Instructions for the MCO · MCO to complete PART II. · MCO must notify BWC via EDI (148) of change of physician within 24 hours of notification by the injured worker. · Return signed copies per distribution listed below. We have received and recorded your request for change of physician. You may bill only medical services and items related to the treatment of the allowed conditions and in accordance with the MCO medical-management guidelines to the MCO or the self-insured employer. The allowed conditions for this workers' compensation claim with corresponding ICD-9-CM codes are as follows: MCO name MCO case manager Distribution: Phone number ( ) Date White­MCO Claim file · Yellow­Injured worker · Pink­Requested physician · Goldenrod­Former physician American LegalNet, Inc. www.FormsWorkFlow.com BWC-1128 (Rev. 9/3/1999) C-23