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Employees Notification Of Intent To Leave Locality Or State And To Change Doctor Or Hospital Form. This is a Utah form and can be use in Workers Compensation.
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Tags: Employees Notification Of Intent To Leave Locality Or State And To Change Doctor Or Hospital, 044, Utah Workers Compensation,
COURT
COUNTY . 03/2000
Form . . . .Revised . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 044 . . . . .OF
EMPLOYEE'S NOTIFICATION OF INTENT TO LEAVE LOCALITY
:
Index No.
OR STATE, AND TO CHANGE DOCTOR OR HOSPITAL
:
Calendar No.
STATE OF UTAH - LABOR COMMISSION
Mail completed form to:
-against-
:
Division of Industrial Accidents
JUDICIAL
Plaintiff(s)
P.O. BOX 146610
:
Salt Lake City, UT 84114-6610
SUBPOENA
:
NOTICE: Injured employees should contact the insurance carrier prior to making plans to leave the state for medical care.
THE CARRIER MAY NOT BE LIABLE FOR ANY OR ALL OF THE COSTS. Other states are not bound by outlimitations on medical fees and you may have to pay the difference between what is allowed in Utah and what the new
:
physician charges. If you have a question as to who the carrier is, ask your employer.
Defendant(s)
:
. . . . . . . . . . . . . . . . . . . INCOMPLETE .OR. UNSIGNED .FORMS .WILL BE RETURNED.
............ .. .......... ...... .
NO ACTION WILL BE TAKEN UNTIL THE ATTENDING PHYSICIAN'S STATEMENT IS RECEIVED.
THE PEOPLE OF THE STATE OF NEW YORK
Name of Employer
Date of Injury
Street TO
Address of Employer
Insurance Carrier
City, State, and Zip of Employer
Employer's Area Code and Telephone Number
GREETINGS:
Name of Employee (Printed)
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
Utah Street Address of Employee
,
the Honorable
at the New: Address of Employee
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
Utah City and Zip Code of Employee
New: City, State, and Zip Code of Employee
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Utah Telephone #
Social Security #
New: Area Code and Telephone #
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
**************************************************************************************************************
the left on whose/intend to Leave
party
behalf this subpoena was issued for onmaximum penalty of I$50 and all have not sustained as a
damages
reported
I
have
the State a (date)
result of your failure to comply.
for a current examination.
to my last Utah physician
Physician's Full Name and Title
Witness, Honorable
Court in
County,
day of
, 20
, one of the Justices of the
Physician's complete address, including zip code and office number
The physician's statement describing my condition when last examined is attached to this request [ ] will be mailed to your office
by the physician [ ].
(Attorney must sign above and type name below)
The treating physician that I have chosen in my new location is:
Dr.
Complete Name (including title)
Attorney(s) for
Street address, Office Number, City, State, and Zip.
New Physician's Area Code and Telephone Number
Employees Signature
Office and P.O. Address
*************************************************************************************************************
Receipt acknowledged by:
Copies mailed to:
Date:
Telephone No.:
Facsimile No.:
Street Address: Heber Wells Bldg, 160 East 300 South, 3rd Floor, Salt Lake City, UT
E-Mail Address:
Mobile Tel. No.:
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