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Respondents Response To Claimants CC Form A Application For Change Of Physician CC-Form-10A - Oklahoma

Respondents Response To Claimants CC Form A Application For Change Of Physician 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-10A Send original to Workers' Compensation Commission and 1 copy to Claimant or the Claimant's Attorney of Record, if any In re claim of: Full Name of Injured Employee (Claimant) WORKERS' COMPENSATION COMMISSION 1915 NORTH STILES AVENUE OKLAHOMA CITY, OKLAHOMA 73105 THIS SPACE FOR COMMISSION USE ONLY Claimant's Social Security Number (LAST 4 DIGITS ONLY) XXX-XX-_________________________ Name of Respondent (Employer) COMMISSION FILE NO. Date of Injury Employer's Insurance Carrier, Permit # for Commission Approved Individual Self-Insured or Own Risk Group, Uninsured NOTE: Mediation is available to help resolve certain workers' compensation disputes. For information, call (405) 522-8760 or In-State Toll Free (800) 522-8210. RESPONDENT'S RESPONSE TO CLAIMANT'S CC-FORM-A APPLICATION FOR CHANGE OF PHYSICIAN [For use ONLY if the worker is NOT subject to a Certified Workplace Medical Plan (CWMP).] Pursuant to 85A O.S., §56(B) and in response to the Claimant's application for change of physician, the respondent presents to claimant the following list of three (3) physicians qualified to treat the claimant's injured body part or condition for which the change of physician is sought: (1) Physician Name, Address and Telephone Number, including Area Code (2) Physician Name, Address and Telephone Number, including Area Code (3) Physician Name, Address and Telephone Number, including Area Code Administrative Workers' Compensation Act, 85A O.S., §6(A)(1)(a): "Any person or entity who makes any material false statement or representation, who willfully and knowingly omits or conceals any material information, or who employs any device, scheme, or artifice, or who aids and abets any person for the purpose of: (1) obtaining any benefit or payment ... shall be guilty of a felony." 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 PUNISHABLE BY IMPRISONMENT, A FINE OR BOTH. Signed this_____________day of_________________________,___________. Signature of Filing Party Address (Number & Street) City Telephone # of Filing Party Print or type name of Attorney Created 2/18/14 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
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