FORM 10A Send original to Court of Existing Claims and 1 copy to Claimant or the Claimant's Attorney of Record In re claim of: Full Name of Injured Employee (Claimant) 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 Respondent (Employer) Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured WCC FILE NO. Date of Injury NOTE: Mediation is available to address certain workers' compensation disputes. For information, call (918) 581-2714. RESPONDENT'S RESPONSE TO CLAIMANT'S FORM-A APPLICATION FOR CHANGE OF PHYSICIAN [For use ONLY if the worker is NOT subject to a Certified Workplace Medical Plan (CWMP).] Respondent rejects the three (3) physicians named in Claimant's Form-A Application for Change of Physician bearing a file-stamped date of _______________, _____, and presents to claimant the following list of three (3) physicians qualified to treat the claimant's injured body part for which the change of physician is sought: (1)_____________________________________________________ (2)_____________________________________________________ (3)_____________________________________________________ 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 Filing Party Address (Number & Street) City Telephone # of Filing Party Print or type name of Attorney Rev. 06/24/2015 I HEREBY CERTIFY THAT ON THIS _______ DAY OF ______________________, _________ A COPY OF THIS FORM WAS MAILED, POSTAGE PREPAID, TO: State Zip Code Opposing Party/Counsel Address (Number & Street) City State Zip Code OBA # American LegalNet, Inc. www.FormsWorkFlow.com