BI-RCP/OO 11/06 Request for Change / Opt-Out Change of Physician Return completed form to: BrickStreet Mutual Insurance P. O. Box 3151 Charleston, WV 25332-3151 Opt-Out of Provider Network 1. Claimant’s Name: 2. Claim Number: 3. Social Security Number: 4. Date of Injury: I am requesting to: Change physicians to another network provider Seek treatment with an out-of-network physician I am presently being treated by: I am requesting to change to: Address of requested physician (Street, City, State, Zip): My reason for changing physicians or seeking treatment out of network: Yes I have checked with the requested physician to see if he / she will take me as a patient: Claimant’s Signature No Date BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332-3151 American LegalNet, Inc. www.FormsWorkflow.com