Fill and Sign the Objection Notice Form

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 Health Care Provider 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 ____. (Attach a copy of the Notice of Change of Health Care Provider) ____ 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 specifc reasons (11.4.4.12(K)(1) NMAC): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _______________________________________ Signature of fling party Rev10/17 11.4.4.9 NMAC Worker’s Name: _____________________________ Worker’s Rep.: ____________________ __________ SSN: _______________________________________ Address: ___________________________________ Date of Accident: _____________________________ City/State/Zip: ______________________________ Mailing Address: _____________________________ Telephone: _________________________________ City/State/Zip: _______________________________ E-mail address for service: _____________________ Telephone: __________________________________ E-mail address for service: ______________________ Employer: ___________________________________ Insurer: ____________________________________ Address: ____________________________________ Address: ___________________________________ City/State/Zip: _______________________________ City/State/Zip: ______________________________ Telephone: __________________________________ Telephone: _________________________________ E-mail address for service: ______________________ E-mail address for service: _____________________ Employer’s Rep.: ______________________________ Address: ____________________________________ City/State/Zip: _______________________________ Telephone: __________________________________ E-mail address for service: ______________________ Rev10/17 11.4.4.9 NMAC