Fill and Sign the Justia Request for Permission for Major Surgery Form

Page 1 of 2 State of Rhode Island and Providence Plantations Providence, S c. W orkers’ Compensation Court Name of Employee XXX-XX- W.C.C. # Social Security Number (last 4 digits only) - vs. - Insurance Carrier Name of Employer Insurance Carrier Address R equest for Permission for Major Surgery The undersigned alleges as follows: The employer has has not been found liable under the terms of the Workers’ Compensation Act for an injury sustained by the employee on __________________. (If applicable, attach a copy of any agreement or decree establishing liability) Dr. _____________________________ has stated that major surgery described as follows is necessary to cure, relieve or rehabilitate the employee from the effects of the inju ry. The proposed surgery is The employee has consented to the procedu re and will undergo the surgery within _________days. Permission for surgery has been requested from the employer or its insurance carrier and has not been received. (Attach copy of such request). Wherefore the employee requests an ex -parte order granting permission for such surgery. Attorney for Employee Employee Address of Attorney Address Attorney phone number and bar registration number Address W.C.C. Pending Cases __________________________ __________________________ Page 2 of 2 W.C.C. No. _________________ EX -PARTE ORDER Permission for surgery is granted to: Name of Surgeon Surgeon Address Surgeon Address S uch surgery shall be performed within ______ days from the date of this order. No liability of any kind is imposed upon the employer or its insurance carrier by this order. Dated this ___________day of _______________________, 20___________. ENTER: PER O RDER : _________________________________________ ____________________________________ Judge Administrator