Send original and 2 copies to Workers' Compensation Commission WORKERS' COMPENSATION COMMISSION 1915 NORTH STILES AVENUE STE 231 OKLAHOMA CITY, OKLAHOMA 73105 THIS SPACE FOR COMMISSION USE ONLY 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 Commission Approved Individual SelfInsured or Own Risk Group, Uninsured COMMISSION FILE NO. Date of Injury CC-FORM-A ORDER FOR CHANGE OF TREATING PHYSICIAN NOW on this _______ day of __________________________, __________, the Workers' Compensation Commission, 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 85A O.S., §56(B) 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 85A O.S., §50, the designated treating physician shall provide the claimant such medical, surgical, hospital, optometric, podiatric, and nursing services, crutches and other apparatus as may be reasonably necessary in connection with the injury to the ____________________________________________________________________________________________ [state injured body part(s)], received by the employee, subject to the diagnostic testing limitation in 85A O.S., §50(C), the Workers' Compensation Commission's closed formulary pursuant to Commission Rule 810:15-5-2, and treatment guidelines of the Official Disability Guidelines published by the Work Loss Data Institute or Physician Advisory Committee Guidelines (PACG) and protocols, if applicable as provided by law. The employer/respondent shall provide the designated physician with a file-stamped copy of this order. BY ORDER OF _____________________________________________________________________ WORKERS' COMPENSATION COMMISSION ADMINSTRATIVE LAW JUDGE Signature: Claimant/Counsel Print: Address (Number and Street) City State Zip OBA# Signature: Employer-Respondent/Counsel Print: Address (Number and Street) City State Zip OBA# Revised 2-2-16 American LegalNet, Inc. www.FormsWorkFlow.com