Utah > Workers Compensation
Employees Notification Of Intent To Leave Locality Or State And To Change Doctor Or Hospital 044 - Utah
| Employees Notification Of Intent To Leave Locality Or State And To Change Doctor Or Hospital Form. This is a Utah form and can be used in Workers Compensation . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Print Form Form 044 EMPLOYEE'S NOTIFICATION OF INTENT TO LEAVE LOCALITY OR STATE, AND TO CHANGE DOCTOR OR HOSPITAL PLEASE PRINT OR TYPE NOTICE: Injured employees should contact the insurance carrier prior to making plans to leave the state for medical care. THE CARRIER MAY NOT BE LIABLE FOR ANY OR ALL OF THE COSTS. Other states are not bound by our limitations on medical fees and you may have to pay the difference between what is allowed in Utah and what the new physician charges. If you have a question as to who the carrier is, ask your employer. INCOMPLETE OR UNSIGNED FORMS WILL BE RETURNED. NO ACTION WILL BE TAKEN UNTIL THE ATTENDING PHYSICIAN'S STATEMENT IS RECEIVED. __________________________________________ Name of Employer ___________________________________ Date of Injury __________________________________________ Street Address of Employer ___________________________________ Insurance Carrier __________________________________________ ` City, State, and Zip of Employer ____________________________________________________ Name of Employee (Printed) ____________________________________________________ Utah Street Address of Employee ___________________________________ Employer's Area Code and Telephone Number _____________________________________ New: Address of Employee ___________________________________________ Utah City and Zip Code of Employee ____________________________________________________ Utah Telephone # Social Security # _____________________________________ New: City, State, and Zip Code of Employee _____________________________________ New: Area Code and Telephone # ************************************************************************************* /intend to leave the State on (date) . I have /have not I left reported to my last Utah physician ____________________________________for a current examination. (Physician's Full Name and Title) ____________________________________________________________________________________ (Physician's complete address, including zip code and office number) The physician's statement describing my condition when last examined is attached to this request . Will be mailed to your office by the physician . The treating physician that I have chosen in my new location is: Dr. _______________________________________ ______________________________________ Complete Name (including title) _______________________________________________ Area Code and Telephone Number Address, Office Number, City, State, Zip ______________________________________ Employee's Signature ************************************************************************************** Receipt acknowledged by __________________________________ Date _______________________ Copies mailed to _____________________________________________________________________ Mail completed form to: Utah Labor Commission Industrial Accidents Division at below address Official Form 044 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
|
|||||||
