Health Care Provider Disagreement Form - Request For Change Of Health Care Provider | | New Mexico

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Health Care Provider Disagreement Form - Request For Change Of Health Care Provider |  | New Mexico

Health Care Provider Disagreement Form - Request For Change Of Health Care Provider

This is a New Mexico form that can be used for Workers Compensation.

Alternate TextLast updated: 7/27/2011

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Description

STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION __________________________________________, Worker, v. __________________________________________, and __________________________________________, Employer/Insurer. WCA No.:___________________________ HEALTH CARE PROVIDER DISAGREEMENT FORM REQUEST FOR CHANGE OF HEALTH CARE PROVIDER A disagreement has arisen over the selection of a health care provider. The _____Worker ______Employer is requesting a change to_________________________________________________________________. (Name of proposed health care provider) The current health care provider's provision of medical care is unreasonable because: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________ Signature of filing party 1. Worker's Name:_____________________________ SSN:______________________________________ Date of Accident:____________________________ Mailing Address:____________________________ City/State/Zip:______________________________ Phone Number:(___)_________________________ 2. Worker's Rep:_______________________ Address:____________________________ City/State/Zip:________________________ Phone Number:(___)___________________ Fax Number:(___)_____________________ 3. Employer:__________________________________ 4. Address:____________________________________ City/State/Zip:_______________________________ Phone Number:(___)__________________________ Fax Number:(___)____________________________ Employer's Rep.:_____________________________ Address:____________________________________ City/State/Zip:_______________________________ Phone Number:(___)__________________________ Fax Number:(___)____________________________ Insurer:_____________________________ Address:____________________________ City/State/Zip:________________________ Phone Number:(___)___________________ Fax Number:(___)_____________________ 5. [This form must be filed with the Clerk of the Workers' Compensation Administration] 11.4.4.9.18.2.L NMAC American LegalNet, Inc. www.FormsWorkFlow.com

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