FORM A Send original to Court of Existing Claims and 1 copy to Each Opposing Party/Counsel In re Claim of: Full Name of Claimant (Injured Employee) COURT OF EXISTING CLAIMS 1915 NORTH STILES, STE 127 OKLAHOMA CITY, OKLAHOMA 73105-4918 THIS SPACE FOR COURT USE ONLY Claimant's Social Security Number (LAST 4 DIGITS ONLY) XXX-XX-_________________________ Name of Employer (Respondent) Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured WCC FILE NO. Date of Injury CLAIMANT'S APPLICATION FOR CHANGE OF PHYSICIAN AND REQUEST FOR HEARING [For use ONLY if the worker is NOT subject to a Certified Workplace Medical Plan (CWMP).] Pursuant to 85 O.S., Section 326(E), CLAIMANT herein respectfully requests that the above captioned matter be set for hearing on the issue of change of physician. In support of this application, claimant states as follows: 1. 2. 3. Claimant is not subject to a certified workplace medical plan. The limit set forth in 85 O.S., §326(E) of no more than two changes of physician per claim, regardless of the number of body parts injured, will not be exceeded if this application for change of physician is allowed. A change of physician is sought for treatment of claimant's _______________________________________(state injured body part), for which authorized medical care has been provided for one hundred eighty (180) days prior to the date of filing this Application. The name of claimant's current treating physician for the injured body part is __________________________________________. Claimant presents to the employer/respondent the following list of three (3) physicians qualified to treat the claimant's injured body part for which a change of physician is sought: (1)________________________________(2) ________________________ (3) _____________________________________________. 4. 5. I declare under penalty of perjury that I have examined all statements contained herein, and to the best of my knowledge and belief, they are true, correct and complete. ANY PERSON WHO COMMITS WORKERS' COMPENSATION FRAUD, UPON CONVICTION, SHALL BE GUILTY OF A FELONY. Signed this _____ day of ________________________, _________. Signature of Claimant Claimant's Address (Number and Street) City Claimant's Telephone Number State Zip Print or Type Name of Attorney for Claimant, if any Signature of Attorney for Claimant Claimant's Attorney's Address (Number and Street) City Claimant's Attorney's Telephone Number State Zip OBA # CERTIFICATE OF SERVICE This is to certify that on this __________ day of ______________________, __________, the foregoing instrument was mailed, postage prepaid to: Opposing Party/Counsel Address (Number and Street) City State Zip Opposing Party/Counsel Address (Number and Street) City State Zip _________________________________________________________________________________ Rev. 06/24/2015 American LegalNet, Inc. www.FormsWorkFlow.com Signature of Claimant or Claimant's Attorney, if any.