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

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

Last updated: 7/27/2011

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

Start Your Free Trial $ 13.99
200 Ratings
What you get:
  • Instant access to fillable Microsoft Word or PDF forms.
  • Minimize the risk of using outdated forms and eliminate rejected fillings.
  • Largest forms database in the USA with more than 80,000 federal, state and agency forms.
  • Download, edit, auto-fill multiple forms at once in MS Word using our Forms Workflow Ribbon
  • Trusted by 1,000s of Attorneys and Legal Professionals

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

Related forms

Our Products