Fill and Sign the Change Workers Compensation Form

Yes No If yes give date of first treatment                                                                                                                                                         Physician moved Physician terminated patient-provider relationship Physician no longer practicing I moved Physician is not a BWC certified provider Dissatisfied with physician's treatment Other, please explain: Please explain:       Please explain:                                                                                                                               ( ) ( ) ( ) ( ) Notice to Change Physician of Record INSTRUCTIONS TO THE INJURED WORKER :• Please complete all of PART I of the form. • Sign in the space provided and submit all copies to your MCO to record your change of physician. Injured worker's name Date of injury Claim number Address Phone number City State 9-digit ZIP Code Please change my physician of record for the above listed claim as follows: From physician: Provider number Address Phone number City State 9-digit ZIP Code To physician: Provider number Address Phone number City State 9-digit ZIP Code Reason for change: Have you been treated by the new physician for the condition(s) allowed in your claim? Injured worker's signature Date INSTRUCTIONS TO THE MCO:• MCO to complete PART II. • MCO must notify BWC via EDI (148) of change of physician within 24 hours of notification by the injured worker. • Return signed copies per distribution listed below. Your request for change of physician has been received and recorded. Only medical services and items related to the treatment of the allowed conditions and in accordance with the MCO medical management guidelines. may be billed to the MCO or the Self-Insured employer. .The allowed conditions for this workers' compensation claim, with corresponding ICD-9-CM codes are as follows: MCO name Phone number MCO case manager Date Distribution: White-MCO Claim file * Yellow-Injured worker * Pink-Requested physician * Goldenrod- Former physician BWC-1128 (Rev. 9/3/1999) C-23