Fill and Sign the Motion State Form

STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION In the Matter of the Approval of: WCA No. ______________________ as a health care provider MOTION FOR APPROVAL OF OUT OF STATE HEALTH CARE PROVIDER COMES NOW , (an injured worker) or (a payor of workers' compensation benefits) and moves the Director for approval, pursuant to, NMSA 1978, §52-4-1(O), of as a health care provider. As grounds therefore, states: 1. The proposed health care provider, (has)(has not) previously provided services to the injured worker in connection with worker's present injury. 2. The proposed health care provider voluntarily submits to the jurisdiction of the Workers' Compensation Administration (WCA), as is more fully set forth in the Affidavit attached hereto. 3. The proposed health care provider (has)(has not) previously applied to the Director of the WCA for approval as a health care provider in this or any other case. If so, supply name of injured worker and injury date of the most recent application for approval. 4. has not sought approval of this proposed health care provider prior to the rendering of services for the following reasons: 5. Concurrence of interested parties and counsel was . ORDER Out of State Health Care Provider Revised 11/19/04 WHEREFORE, respectfully requests the Director approve, pursuant to §52-4-1-(O) as a health care provider. ____________________________________ Signature ____________________________________ (Representative) (Attorney) ____________________________________ Address ____________________________________ City/State/Zip ____________________________________ Telephone CERTIFICATE OF MAILING I certify that the foregoing Motion was mailed to: ______________________________ at: on this day of , 2004. ____________________________________ Calendar Clerk ORDER Out of State Health Care Provider Revised 11/19/04 STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION In the matter of the approval of WCA No. _______________________ AFFIDAVIT 1. I, , being duly sworn, state: I am licensed as a , in the state of , and my license to practice is currently in good standing; 2. I agree to be bound by the schedule of maximum allowable payments and schedule of non-clinical fees currently in force and effect in New Mexico; 3. I agree to be bound by all Workers' Compensation Administration (WCA) rules and regulations and by the Workers' Compensation Act of the state of New Mexico; 4. I agree to cooperate with the current and any successor medical cost containment contractors engaged by the WCA pursuant to statute; 5. (I irrevocably designate as my New Mexico agent name if agent for service of process in this cause) or (I agree to accept service of process by mail in this cause); 6. I agree to honor any subpoena or notice of deposition served upon me in the manner set forth above, and (to appear in New Mexico for all depositions and hearings as required) (appear telephonically at all depositions and hearings with the permission of the Court); 7. I submit to the personal jurisdiction of the WCA and any of the New Mexico courts of competent jurisdiction for purposes of any Workers' Compensation matter; ORDER Out of State Health Care Provider Revised 11/19/04 8. I state here that I understand that the designation as a health care provider applies only to the injuries sustained by in an incident alleged to have occurred on or about , and that I understand that I have no authority to refer this patient to another health care provider who is not licensed by the state of New Mexico; 9. I understand that my designation as a health care provider can be revoked, suspended or conditioned, by written order of the Director of the WCA, at any time, with or without cause; and; 10. I understand that if my license to practice in is suspended or revoked, my designation as a New Mexico health care provider is automatically revoked, with or without notice by the Director of the Workers' Compensation Administration. ____________________________________ Signature ____________________________________ Health Care Provider ____________________________________ Address ____________________________________ City/State/Zip ____________________________________ Telephone ORDER Out of State Health Care Provider Revised 11/19/04 ACKNOWLEDGMENT STATE OF ) ) ss. COUNTY OF ) Subscribed and sworn to before me this day of , 2004. ____________________________________ Notary Public My commission expires: ___________________ ORDER Out of State Health Care Provider Revised 11/19/04 STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION In the Matter of the Approval of: WCA No. _________________ ORDER FOR APPROVAL OF OUT OF STATE HEALTH CARE PROVIDER THIS MATTER coming before the Director, pursuant to NMSA 1978, §52-4-1(O), and having reviewed the Motion and Affidavit of the proposed health care provider; the Director FINDS; 1. The proposed health care provider is licensed in the state of . 2. The proposed health care provider has given assurances in the form of an affidavit to the Director, that his/her authorization to act as a health care provider in this particular case will not unduly disrupt the operation of the workers' compensation system in the state of New Mexico. 3. Subject to the conditions set forth in the Affidavit, provisions concerning health care provider choice, and the determination of the Workers' Compensation Judge concerning admissibility and credibility of testimony, good cause exists to approve , as a health care provider with respect to the injuries of , allegedly sustained on or about . ORDER Out of State Health Care Provider Revised 11/19/04 IT IS THEREFORE ORDERED that, subject to the terms and conditions in the Affidavit of the proposed health care provider; incorporated herein as if fully set forth, is approved as a health care provider pursuant to §52-4-1(O) for treatment of the injuries of allegedly sustained on or about , , provided however, that nothing in this Order shall be construed to affect, in any way, the rights and obligations of the parties pursuant to statutory provisions and promulgated rules concerning health care provider choice; and that nothing in this Order shall be construed to affect, in any way, the acceptance or admissibility of the testimony of any health care provider by any Workers' Compensation Judge or the credibility or weight to be ascribed to such testimony by the Workers' Compensation Judge. GLENN R. SMITH WCA Director ORDER Out of State Health Care Provider Revised 11/19/04