Fill and Sign the Workplace Injuries and the Take Up of Social Security Form

Form 102 APPLICATION TO CHANGE DOCTORS PLEASE PRINT OR TYPE ________________________________________ Carrier File No. _______________________________ Name of Injured Person ________________________________________ Social Security No. ___________________________ Home Address (street) ________________________________________ ____________________________________________ City/State/Zip Home Phone Number On ____________________, 20 _____, I sustained an injury/occupati onal disease arising out of and in the course of my employment at______________________________________________________________ Employer Name _____________________________________________________________________________________________________ Employer Address _ _____________________________________________________________________ _________________________________ City / State/ Zip Ph one Number Briefly describe how accident occurre d, parts of body injured, and results ___________________________ ________________________________________________________________________\ _______________ ________________________________________________________________________\ _______________ I have been treated by the follo wing doctors (Give full names and addresses in the order in which they were seen):________________________________________________________________________\ ___________ ________________________________________________________________________\ _______________ ________________________________________________________________________\ _______________ I asked my present doctor for a referral. Yes _____ No _____Referral was approved. Yes No ____ I would like permission to change from Dr. ___________________________________________________ ________________________________________________________________________\ _______________ (Give full name, title [M.D., D. C., etc.], address and zip) To Dr. ________________________________________________________________________\ _________ (Give full name, title [M.D., D.C., etc.], address and zip) My reasons for wanting to change are _______________________________________________________ ________________________________________________________________________\ _______________ ________________________________________________________________________\ _______________ ________________________________________________________________________\ _______________ MAIL THIS REQUEST TO: Insura nce Carrier/Adjustor ________________________________________ Street or Mailing Address ________________________________________ City, State, Zip ________________________________________________ ACTION ON REQUEST Approved by: ______________________________ Date:_______________________________________ Denied by: _________________________________ Date:_______________________________________ Reasons for denial: ______________________________________________________________________ ________________________________________________________________________\ ______________ *** Copies of this form approved or denied, must be mailed promptly to the applicant and to the doctor the applicant has requested to be the treating physician. Official Form 102 Revised 10/14 State of Utah * Labor Commission * Division of Industrial Accidents 160 East 300 South * P.O. Box 146610 Salt Lake City, UT 84114-6610 * Telephone: 801- 530-6800 * Fax: 801-530-6804 * Toll Free: (800) 530-5090 * www.laborcommission.utah.gov