Fill and Sign the Notice of Change of Health Care Provider under Automatic Right of Second Selection New Mexico Form

NEW MEXICO WORKERS’ COMPENSATION ADMINISTRATION NOTICE OF CHANGE OF HEALTH CARE PROVIDER A party has fied a Notice of Change of Heaith Care Provider in your workers’ compensation case pursuant to Section 52-1-49 of the New Mexico Workers’ Compensation Act or Section 52-3-15 of the New Mexico Occupationai Disabiement Law. If you are the injured worker, you must change to the heaith care provider named beiow within 10 days of the postmark or deiivery date of this notice. You may object to the change by fiing an “Heaith Care Provider Disagreement Form” with the Workers’ Compensation Administration within 3 days of receipt of this notice. If you do not fie the Objection within 3 days, the change wiii be binding. If you fie the Objection after 3 days, the change wiii remain in efect uniess it is changed by the court. The party making the change is:________________________________________________________________ This notice was sent to:_______________________________________________________________________ Worker’s Name:_______________________________ Empioyer’s Name:_____________________________ Address:_____________________________________ Address:_____________________________________ _____________________________________ ______________________________________ Teiephone No.:_______________________________ Teiephone No.:________________________________ Insurance Company:___________________________ Ciaims Representative:_________________________ Address:_____________________________________ Teiephone No.:_______________________________ _____________________________________ Worker’s Attorney, if any:_______________________ Empioyer’s Attorney, if any:_____________________ Address:_____________________________________ Address: ____________________________________ _____________________________________ ____________________________________ Date of Accident:______________________________ County of Accident:____________________________ Type of Injury:______________________________________________________________________________ Current heaith care provider:__________________________________________________________________ Address:_____________________________________ Teiephone No.:______________________________ _____________________________________ Proposed heaith care provider (must be iicensed in New Mexico):_____________________________________ Address:_____________________________________ Teiephone No.:______________________________ _____________________________________ Rev. 10/17 11.4.4.12 (D) Signature of Person sending this Notice :________________________________ Date: __________________ Your rights may be afected by your faiiure to respond to this notice: if you need assistance and are not represented by an attorney, contact an ombudsman of the WCA Albuquerque: (505) 841-6000 or 1 (800) 255-7965 Farmington: (505) 599-9746 or 1 (800) 568-7310 Las Cruces: (575) 524-6246 or 1 (800) 870-6826 Las Vegas: (505) 454-9251 or 1 (800) 281-7889 Hobbs: (575) 397-3425 or 1(800) 934-2450 Roswell: (575) 623-3997 or 1 (866) 311- 8587 Santa Fe: (505) 476-7381 HCP Optionai Form, Ruie 4.4.11.5.2 Workers’ Compensation Handbook