COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Notice to Change Physician of RecordBetter Workers CompensationCalendar No.The physician selected must be BWC certified or the injured worker will be responsible for payment. INSTRUCTIONS TO THE INJURED WORKER: Please complete all of PART I of the form. Sign in the space provided and submit all copies to your MCO to record your change of physician.Built with you in mind.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)PART IInjured worker's nameClaim number Date of injuryPhone number (Address)9-digit ZIP Code State City. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Please change my physician of record for the above listed claim as follows:Provider numberFrom physician:AddressPhone number (THE PEOPLE OF THE STATE OF NEW YORK TO)9-digit ZIP Code State CityProvider numberTo physician:Phone number (GREETINGS:) Address9-digit ZIP Code State CityWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableReason for change:,located at County ofPhysician no longer practicingI movedPhysician is not a BWC certified providerPhysician movedo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomDissatisfied with physician's treatment Please explain:Other, please explain:Physician terminated patient-provider relationship Please explain:Your failure to comply with 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 result of your failure to comply.Have you been treated by the new physician for the condition(s) allowed in your claim?If yes give date of first treatmentNoYesDate Injured worker's signature, one of the Justices of theCourt in Witness, Honorableday of, 20 County,INSTRUCTIONS TO THE MCO: MCO to complete PART II. MCO must notify BWC via EDI (148) of change of physician within 24 hours of notification by the injured worker. Return signed copies per distribution listed below.(Attorney must sign above and type name below)PART IIYour request for change of physician has been received and recorded. Only medical services and items related to the treatment of the allowed conditions and in accordance with the MCO medical management guidelines, may be billed to the MCO or the Self-Insured employer. The allowed conditions for this workers' compensation claim, with corresponding ICD-9-CM codes are as follows:Attorney(s) forOffice and P.O. AddressPhone number (MCO nameTelephone No.: Facsimile No.: E-Mail Address:)DateMCO case managerWhiteMCO Claim file YellowInjured worker PinkRequested physician GoldenrodFormer physicianDistribution:Mobile Tel. No.:BWC-1128 (Rev. 9/3/1999) C-23American LegalNet, Inc. www.USCourtForms.com
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