Idaho > Workers Compensation > Attorney
Petition For Change Of Physician - Idaho
| Petition For Change Of Physician Form. This is a Idaho form and can be used in Attorney Workers Compensation . |
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PETITION FOR CHANGE OF PHYSICIAN Employee Name and Address: Employer Name and Address: Telephone Number: Social Security Number: Current Physician and Address: Surety Name and Address (if known): Requested Physician and Additional Information or Address: Documentation Attached (Circle One): No Yes Date of Injury/Disease: General Information: Medical Treatment to Date: Reason for Change: Hearing Date/Time Availability Next 30 Days: Date: ____________ Signature:____________________________________ ORIGINAL TO EMPLOYER OR SURETY Copy to Idaho Industrial Commission, 317 Main St., PO Box 83720, Boise, ID 83720-0041, or fax to 208-332-7558. (Rev. 1/01/2004) Appendix 7A Petition - Page 1 of 2 <<<<<<<<<********>>>>>>>>>>>>> 2 CERTIFICATE OF SERVICE I hereby certify that on the _____ day of ____________, 20___, I caused to be served the Original Petition for Change of Physician upon either the following Employer or its Surety: EMPLOYERS NAME AND ADDRESS SURETYS NAME AND ADDRESS ___________________________ OR ____________________________ ___________________________ ____________________________ ___________________________ ____________________________ via: ( ) Personal Service of Process ( ) Personal Service of Process via: ( ) Regular U. S. Mail ( ) Regular U.S. Mail I also hereby certify that on the _____ day of ____________, 20___, I caused to be served a true and correct copy of the foregoing Petition for Change of Physician upon: Idaho Industrial Commission 317 Main Street Post Office Box 83720 Boise, Idaho 83720-0041 via: ( ) Personal Service of Process ( ) Regular U. S. Mail ( ) Faxed to 208-332-7558 __________________________ Signature Petition - Page 2 of 2
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