Fill and Sign the Oklahoma Workers Compensation Commission Contact Us Form

CC-FORM -9 Send original to: Workers’ Compensation Commission and 1 copy to Each Opposing Party/Counsel WORKERS’ COMPENSATION COMMISSION 1915 NORTH STILES AVENUE STE 231 OKLAHOMA CITY, OKLAHOMA 73105 Full Name of Claimant (Injured Employee) Claimant’s Social Security Number (LAST 4 DIGITS ONLY) XXX -XX- ________________________ Name of Employer (Respondent) In re claim of: REQUEST FOR HEARING Commission File Number Date of Injury Administrative Workers’ Compensation Act, 85A O.S., §6(A)(1)(a): “Any person or entity who makes any material false statement or representation, who willfully and knowingly omits or conceals any material information, or who employs any device, scheme, or artifice, or w ho aids and abets any person for the purpose of: (1) obtaining any benefit or payment … shall be guilty of a felony.” Any person who commits workers’ compensation fraud, upon conviction, shall be guilty of a felony punishable by imprisonment, a fine or both. The undersigned declare under PENALTY OF PERJURY that they have examined all statements contained herein, and to the best of their knowledge and belief, they are true, correct and complete. Revised 2 -2- 16 NOTE: Mediation is available to help resolve certain workers’ compensation disputes. For information, call (405) 522 -5308 or In- S t a t e Toll Free (855) 291-3612. 1. Issues to be tried: (Mark all applicable issues below.) a. Temporary Total Disability from ________________________ to _______________________________. b. Medical Treatment from _____________________________ to ________________________________ . c. Permanent Partial Disability. d. Permanent Total Disability. e. Claim for additional compensation per 85A O.S., § 80 for Reopen on Change of Physical Condition. Has the Reopen Fee been paid? YES NO f. Change of Physician for a worker covered by a Certified Workplace Medical Plan (CWMP). ( Note: File a CC -Form -A to set a Request for Change of Physician when the worker is NOT covered by a CWMP.) g. Change of Case Manager for a worker not covered by Certified Workplace Medical Plan (CWMP). h. Liability of Multiple Injury Trust Fund. i. Rate: TTD____________________PPD ____________________ PTD __________________ AWW_________________. j. Death Benefits. k. MFDR Form 19 (Provider Request for Medical Fee Dispute Resolution). Was the MFDR Form 19 filed previously with the Commission? YES NO l. Other (SPECIFY) __________________________________________________________________________________________. (ALL DEPOSITIONS OF MEDICAL EXPERTS SHALL BE COMPLETED PRIOR TO THE HEARING BEFORE THE ADMINISTRATIVE LAW JUDGE .) 2. List the names of all witnesses who may be called at hearing: ____________________________________________________________ ______________________________________________________________________________________________________________ 3. List all exhibits to be introduced at hearing: __________________________________________________________________________ ______________________________________________________________________________________________________________ 4. Requestor hereby certifies that a copy of the medical report written by Dr. _________________________________________and dated _____________________________ was mailed, together with a copy of the REQUEST FOR HEARING, to the Opposing Party/Counsel. (REFER TO COMMISSION RULES ON THE EXCHANGE OF EXHIBITS.) Do NOT attach a copy of the medical report when filing the CC -Form -9 with the Workers’ Compensation Commission. I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO: Signed this ____________day of_________________________________ ,___________. THIS SPACE FOR COMMISSION USE ONLY (Please Type or Print) Employer’s Insurance Carrier, Permit # for Commission Approved Individual Self -Insured or Group Self -Insurance Association Signature of □ Respondent □ Claimant □ Provider □ Counsel for Requestor Address (Number & Street) City State Zip Code Telephone # of Filing Party Print or type Name of Attorney OBA # Opposing Party/Counsel Address (Number & Street) City State Zip Code