Fill and Sign the Forms New Mexico Workers Compensation Administration

Rev10/17 11.4.4.9 NMAC STATE OF NEW MEXICO WORKERS’ COMPENSATION ADMINI STRATION _________________________________________________, WCA No.:_______________ Worker, v. _________________________________________________, and _________________________________________________, Employer/Insurer. HEALTH CARE PROVIDER DISAGREEMENT FORM A disagreement has arisen over the selection of Health Care Provider (HCP) , or provision of health care services pursuant to 11.4.4.12 NMAC . Check the appropriate reason for the H ealth Care P rovider disagreement. ____ Applicant disagrees with the Notice of Change of Health Care Provider pursuant to 11.4.4. 12(F)(1) or (F)(2) NMAC .: A Notice of Change of HCP was served by: __ _ Worker __ _ Employer on __ __ ____________ ____, 2 0____. (At tach a copy of the Notice o f Change of Health Care Pro vider ) ____ Applicant disagrees that the authorized HCP is providing the worker reasonable and necessary medical care and requests a change in HCP . Pursuant to 11.4.4.12(L) NMAC , the applicant bears the burden of proof to show that the worker is not receiving reasonable and necessary medical care or the request will be denied . Applicant may suggest an alternate HCP pursuant to 11.4.4.12(K)(2) NMAC : Applicant objects to the authorized HCP for the following specific reasons (11.4.4.12(K)(1) NMAC) : ____ ___________________________ ______ __ Signature of filing party Rev10/17 11.4.4.9 NMAC Wo rker’s Rep.: ____________________ __________ Address: ____________ _______________________ City/State/Zip: _____ __________ ____ ______ _____ T elephone : ___ __________ ______________ ___ ___ E- mail a ddress for service: ________________ ____ _ Worker’s Name: __ ________________________ ___ SSN: ____ ________________ _________ ________ __ Date of Acci dent: ___ ____ ____ ______________ ___ Mailing Address: _ __ ___________ ______________ _ City/State/Zip: ________________ _______________ Telephone : _____________________ ____________ E-m ail address for service: ___________________ __ Insurer: _________________________ ___________ A ddress: _______________________ ______ _____ _ City/State/Zip: _________________ _____ ________ Telephone : ________ ___________ _____ _____ ____ Employer :_________________ __________________ Address: ___________________________________ _ City/State/Zip: ___________________ ____________ Telephone :______________________ ____________ E-m ail address for service: ________ ____________ _ E-mail address for service: ___________________ __ Employer’s Rep.: _ _____________________________ Address: ______________________ ______________ City/State/Zip: _______________________________ Telephone :___ ______________________________ E-m ail address for service: _____________________