Application To Change Doctors
Application To Change Doctors Form. This is a Utah form and can be use in Workers Compensation.
Tags: Application To Change Doctors, 102, Utah Workers Compensation,
COURT COUNTY OF . . . . . . . . 03/2000 Form.102. Revised . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : Index STATE OF UTAH - LABOR COMMISSION No. Division of Industrial Accidents P. 0. Box 146610 : Calendar No. Salt Lake City, UT 84114-6610 : (801) 530-6800 1-800-530-5090 TDD(801)530-7685 JUDICIAL SUBPOENA Plaintiff(s) -against- : APPLICATION TO CHANGE DOCTORS : Carrier File No: Name of Injured Person : Social Security No: : Home Address. (street). . . . . . . . . . . . . . . . . . . . . . . .Defendant(s) . . . . . . . ....... ..... .......... City/State/Zip Home Phone Number On THE PEOPLE OF 20 STATE OF NEW YORK , THE , I sustained an injury/occupational disease arising out of and in the course of my employment, while employed by: TO Phone Number Employer Name City/ State/ Zip Address GREETINGS: Briefly describe how accident occurred, parts of body injured, and results: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at I haveCounty of been treated by the following doctors (Give full names and addresses in the order in which they were seen): in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the No I asked my present doctor for a referral. Yes Referral was approved. Yes No I would like permission to change: From Dr. this subpoena is punishable as a contempt of court and will make you liable to Your failure to comply with the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Give full name, title (M.D., D.C., etc.), address and zip To Dr. Witness, Honorable Give full name, title (M.D., D.C., etc.), address and zip the Justices of the , one of My reasons for wanting to change are: Court in County, day of , 20 MAIL THIS REQUEST TO: Approved by: Denied by: Reasons for denial: *** (Attorney must sign above and type name below) Insurance Carrier/Adjustor: Street or Mailing Address: City, State, Zip: Attorney(s) for ACTION ON REQUEST Date: Date: Office and P.O. Address Copies of this form approved or denied, must be mailed promptly to the applicant and to the doctor, Telephone No.: whom the applicant has requested to be the treating physician. See rule on back! Facsimile No.: E-Mail Address: Street Address: Heber Wells Bldg, 160 East 300 South, 3rd Floor, Salt Lake City, UT Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. R612. Labor Commission - Industrial Accidents. R612-2. Workers' Compensation Rules - Health Care Providers. Calendar No. : R612-2-9. Changes of Doctors and Hospitals. : A. It shall be the responsibility of Plaintiff(s) the insurance carrier or self-insured employer to notify each JUDICIAL SUBPOENA claimant of the change of-against-rules. Those rules are as follows: doctor : 1. If a company doctor, designated facility or PPO is named, the employee must first treat with that designated provider. The insurance carrier or self-insured employer shall be responsible for payment : for the initial visit, less any health insurance copays and subject to any health insurance reimbursement, if : the employee was directed to and treated by the employer's or insurance carrier's designated provider, and liability for the claim is denied and if the treating physician provided treatment in good faith and provided Defendant(s) : ...................................................... the insurance carrier or self-insured employer a report necessary to make a determination of liability. Diagnostic Studies beyond plain x-rays would need prior approval unless the claimed industrial injury or occupational illness required emergency diagnosis and treatment. THE PEOPLE OFemployee may make one change of doctor without requesting the permission of the carrier, 2. The THE STATE OF NEW YORK so long as the carrier is promptly notified of the change by the employee. TO (a) Physician referrals for treatment or consultation shall not be considered a change of doctor. (b) Changes from emergency room facilities to private physicians, unless the emergency room is named as the ''company doctor'', shall not be considered a change of doctor. However, once private GREETINGS: has begun, emergency room visits are prohibited except in cases of. physician care (i) COMMAND YOU, that all or WE Private physician referral, business and excuses being laid aside, you and each of you attend before (ii) , the HonorableThreat to life. at the Court County of 3. Regardless of priorlocated at a change of doctor shall be automatically approved if the treating changes, in room , refuses day permanent partial impairment. , 20 , at o'clock in the noon, and at any recessed physician fails oron the to rate of or adjourned date, to testify and give those listedaabove made without thethe part of the the carrier/self-insurer B. Any changes beyond evidence as witness in this action on permission of may be at the employee's own expense if. 1. The employee has received notification of rules, or Your failure to comply withmade. 2. A denial of request is this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a C. failure to comply. result of your An injured employee who knowingly continues care after denial of liability by the carrier may be individually responsible for payment. It shall be the burden of the carrier to prove that the patient was aware of the denial. Witness, Honorable , one of the Justices of the D. It shall County, be the responsibility of the employee to make the proper filings with the division when Court in day of , 20 changing locale and doctor. Those forms can be obtained from the division. E. Except in special cases where simultaneous attendance by two or more medical care practitioners has been approved by the carrier/employer or(Attorney must sign above and type name below) are being the division, or specialized services provided the employee by another physician under the supervision and/or by the direct referral of the treating physician, the injured employee may be attended by only one practitioner and fees will not be paid Attorney(s) to two practitioners for similar care during the same period of time. for F. The Commission has jurisdiction to decide liability for medical care allegedly related to an industrial accident. Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com