Send original and 2 copies to Court of Existing Claims COURT OF EXISTING CLAIMS 1915 NORTH STILES, STE 127 OKLAHOMA CITY, OKLAHOMA 73105-4918 THIS SPACE In re Claim of: Full Name of Claimant (Injured Employee) 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 FORM-A ORDER FOR CHANGE OF TREATING PHYSICIAN NOW on this _______ day of __________________________, __________, the Court of Existing Claims, being well and fully advised in the premises, FINDS AND ORDERS AS FOLLOWS: THAT the claimant is not covered by a Certified Workplace Medical Plan. THAT the respondent admits claimant sustained a compensable injury arising out of and in the course of employment with respondent on the date above stated to the _________________________________________________________________ [state injured body part(s)]. THAT the claimant's application for change of treating physician pursuant to 85 O.S., Section 326(E) is proper and hereby granted. IT IS THEREFORE ORDERED that Dr. _______________________________________________________ is designated as the claimant's treating physician for treatment of the claimant's ___________________________________________________________ [state injured body part(s)]. IT IS FURTHER ORDERED that per 85 O.S., Section 326, the designated treating physician shall provide the claimant such medical, diagnostic, surgical or other attendance or treatment, nurse and hospital service, medicine, crutches and apparatus as may be reasonable and necessary after the claimant's compensable injury to the ____________________________________________________ __________________________________________________ [state injured body part(s)], subject to the diagnostic testing limitation in 85 O.S., Section 326(F) and treatment guidelines of the Work Loss Data Institute's Official Disability Guidelines (ODG) or Physician Advisory Committee's Oklahoma Treatment Guidelines (OTG), as applicable. The respondent shall provide the designated physician with a file-stamped copy of this order. BY ORDER OF _____________________________________________________________________ COURT OF EXISTING CLAIMS JUDGE Signature: Claimant/Counsel Print: Address (Number and Street) City Rev. 06/24/2015 American LegalNet, Inc. www.FormsWorkFlow.com Signature: Employer-Respondent/Counsel Print: Address (Number and Street) State Zip City State Zip