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Application For Change Of Physician And Request For Hearing CC-Form-A - Oklahoma

Application For Change Of Physician And Request For Hearing Form. This is a Oklahoma form and can be used in Workers Comp .
 Fillable pdf Last Modified 3/18/2014
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CC-FORM-A S 1 I F N 'C E C O C P WORKERS' COMPENSATION COMMISSION 1915 NORTH STILES VENUE OKL HOM CITY OKL HOM 73105 /C THIS SP CE FOR COMMISSION USE ONLY C (I j E ) C 'S S N b (L ST 4 DIGITS ONLY) XXX-XX-_________________________ N E (R ) COMMISSION FILE NO. E 'I C P # C I S -I ORG U 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. D Ij CLAIMANT'S APPLICATION FOR CHANGE OF PHYSICIAN AND REQUEST FOR HEARING [F ONLY NOT bj C M P (C MP). P 1. 2. C 5 O.S. 5 (B) CL IM NT .I bj j . b : b _______________________________________ ( 3. A A fi I , S S C ' _________________________________________________________ b ). T W b . 'C ' A, ' PENALTY OF PERJURY , . _________ ______________________________________________________________. A O.S., : (1) b , I x A b , , ... b ." , ______________________________________________ ______________. P T N C OB # C ' (N b S ) S C C S Z C ' ' (N b S ) C 'T N b C S Z C ' 'T N b CERTIFICATE OF SERVICE T __________ _____________________________________ __________ FOR CH NGE OF PHYSICI N ND REQUEST FOR HE RING : O P /C CL IM NT'S PPLIC TION O P /C (N b S ) (N b S ) C S Z C S Z ___________________________________________________________________________________________ C 2- - 4 S C C 'A , American LegalNet, Inc. www.FormsWorkFlow.com
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