Fill and Sign the Health Form Request Change

STATE OF NEW MEXICO WORKERS’ COMPENSATION ADMINISTRATION __________________________________________, WCA No.:___________________________ Worker, v. __________________________________________, and __________________________________________, Employer/Insurer. 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:_____________________________ 2. Worker’s Rep:_______________________ SSN:______________________________________ Address:____________________________ Date of Accident:____________________________ City/State/Zip:________________________ Mailing Address:____________________________ Phone Number:(___)___________________ City/State/Zip:______________________________ Fax Number:(___)_____________________ Phone Number:(___)_________________________ 3. Employer:__________________________________ 4. Insurer:_____________________________ Address:____________________________________ Address:____________________________ City/State/Zip:_______________________________ City/State/Zip:________________________ Phone Number:(___)__________________________ Phone Number:(___)___________________ Fax Number:(___)____________________________ Fax Number:(___)_____________________ 5. Employer’s Rep.:_____________________________ Address:____________________________________ City/State/Zip:_______________________________ [This form must be filed with the Clerk of Phone Number:(___)__________________________ the Workers’ Compensation Administration] Fax Number:(___)____________________________ 11.4.4.9.18.2.L NMAC