Utah > Workers Compensation
Application To Change Doctors 102 - Utah
| Application To Change Doctors Form. This is a Utah form and can be used in Workers Compensation . |
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Print Form Form 102 APPLICATION TO CHANGE DOCTORS PLEASE PRINT OR TYPE ______________________________________________ Name of Injured Person Carrier File No. _________________________ Social Security No. ______________________ ______________________________________ Home Phone No. ______________________________________________ Home Address (street) _____________________________________________ City/State/Zip On , 19 , I sustained an injury/occupational disease arising out of and in the course of my employment at: ___________________________________________________________________ ______________________________________________________________________________________ Employer Name Address Phone Number City/ State/ Zip _____________________________________________________________________________________ Briefly describe how accident occurred, parts of body injured, and results: ___________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ I have been treated by the following doctors (Give full names and addresses in the order in which they were seen):___________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ________________________________________________________________ I asked my present doctor for a referral. Yes No Referral was approved. Yes No _____ I would like permission to change from Dr. ___________________________________________________ _______________________________________________________________________________________ (Give full name, title [M.D., D.C., etc.], address and zip) To Dr. _________________________________________________________________________________ (Give full name, title [M.D., D.C., etc.], address and zip) My reasons for wanting to change are: _______________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ MAIL THIS REQUEST TO: Insurance Carrier/Adjustor: ______________________________________ Street or Mailing Address: _______________________________________ City, State, Zip: ACTION ON REQUEST Approved by: Date: __________________________________ Denied by: Date: _______________________________ Reasons for denial: ______________________________________________________________________ _______________________________________________________________________________________ ** Copies of this form approved or denied, must be mailed promptly to the applicant and to the doctor, whom the applicant has requested to be the treating physician. See rule on back! Official Form 102 Revised 2/09 State of Utah Labor Commission Division of Industrial Accidents 160 East 300 South P.O. Box 146610 Salt Lake City, UT 84114-6610 Telephone: (801) 530-6800 Fax: (801) 530-6804 Toll Free: (800) 530-5090 www.laborcommission.utah.gov American LegalNet, Inc. www.FormsWorkFlow.com R612. Labor Commission Industrial Accidents. R612-2. Workers' Compensation Rules Health Care Providers R612-2-9. Changes of Doctors and Hospitals. A. It shall be the responsibility of the insurance carrier or self-insured employer to notify each claimant of the change of doctor rules. Those rules are as follows: 1. If a company doctor, designated facility or PPO is named, the employee must first treat with that designated provider. The insurance carrier or self-insured employer shall be responsible for payment for the initial visit, less any health insurance copays and subject to any health insurance reimbursement, if the employee was directed to and treated by the employer's or insurance carrier's designated provider, and liability for the claim is denied and if the treating physician provided treatment in good faith and provided the insurance carrier or self-insured employer a report necessary to make a determination of liability. Diagnostic studies beyond plain X-rays would need prior approval unless the claimed industrial injury or occupational illness required emergency diagnosis and treatment. 2. The employee may make one change of doctor without requesting the permission of the carrier, so long as the carrier is promptly notified of the change by the employee. (a) Physician referrals for treatment or consultation shall not be considered a change of doctor. (b) Changes from emergency room facilities to private physicians, unless the emergency room is named as the "company doctor," shall not be considered a change of doctor. However, once private physician care has begun, emergency room visits are prohibited except in cases of: (i) Private physician referral, or (ii) Threat to life. 3. Regardless of prior changes, a change of doctor shall be automatically approved if the treating physician fails or refuses to rate permanent partial impairment. B. Any changes beyond those listed above made without the permission of the carrier/self-insurer may be at the employee's own expense if: 1. The employee has received notification of rules, or 2. A denial of request is made. C. An injured employee who knowingly continues care after denial of liability by the carrier may be individually responsible for payment. It should be the burden of the carrier to prove that the patient was aware of the denial. D. It shall be the responsibility of the employee to make the proper filings with the division when changing locale and doctor. Those forms can be obtained from the division. E. Except in special cases where simultaneous attendance by two or more medical care practitioners has been approved by the carrier/employer or the division, or specialized services are being provided the employee by another physician under the supervision and/or by the direct referral of the treating physician, the injured employee may be attended by only one practitioner and fees will not be paid to two practitioners for similar care during the same period. F. The Commission has jurisdiction to decide liability for medical care allegedly related to an industrial accident. American LegalNet, Inc. www.FormsWorkFlow.com
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