Fillable Cc-Form-A - Claimant'S Application For Change Of Physician And Request For Hearing printable pdf download

THIS SPACE FOR COMMISSION USE ONLY

CC-FORM-A

WORKERS’ COMPENSATION COMMISSION

1915 NORTH STILES AVENUE STE 231

Send original to

OKLAHOMA CITY, OKLAHOMA 73105

Workers’ Compensation Commission and

1 copy to Each Opposing Party/Counsel

In re Claim of:

Full Name of Claimant (Injured Employee)

Claimant’s Social Security Number (LAST 4 DIGITS ONLY)

XXX-XX-_________________________

Name of Employer (Respondent)

COMMISSION FILE NO.

Employer’s Insurance Carrier, Permit # for Commission Approved Individual Self-Insured

Date of Injury

or Own Risk Group, Uninsured

I declare under penalty of perjury that I have examined all statements contained herein, and to the best of my knowledge and belief, they are true,

correct and complete. ANY PERSON WHO COMMITS WORKERS’ COMPENSATION FRAUD, UPON CONVICTION, SHALL BE GUILTY OF A FELONY.

CLAIMANT’S APPLICATION FOR CHANGE OF PHYSICIAN AND REQUEST FOR HEARING

[For use ONLY if the worker is NOT subject to a Certified Workplace Medical Plan (CWMP).]

Pursuant to 85A O.S., §56(B), CLAIMANT herein respectfully requests that the above captioned matter be set for hearing on the

issue of change of physician. In support of this application, claimant states as follows:

1. Claimant is not subject to a certified workplace medical plan.

2. A change of physician is sought for treatment of claimant’s _________________________________________________________

_______________________________________ (state injured body part).

3. The name of claimant’s current treating physician is ______________________________________________________________.

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 who 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.

I declare under PENALTY OF PERJURY that I have examined all statements contained herein, and to the best of my knowledge and

belief, they are true, correct and complete.

Signed this _________ day of ______________________________________________, ______________.

Signature of Claimant

Print or Type Name of Attorney for Claimant, if any

OBA #

Claimant’s Address (Number and Street)

Signature of Attorney for Claimant

City

State

Zip

Claimant’s Attorney’s Address (Number and Street)

Claimant’s Telephone Number

City

State

Zip

Claimant’s Attorney’s Telephone Number

CERTIFICATE OF SERVICE

This is to certify that on this __________ day of _____________________________________, __________, the foregoing CLAIMANT’S APPLICATION

FOR CHANGE OF PHYSICIAN AND REQUEST FOR HEARING was mailed, postage prepaid to:

Opposing Party/Counsel

Address (Number and Street)

City

State

Zip

City

State

Zip

___________________________________________________________________________________________

Signature of Claimant or Claimant’s Attorney, if any

Revised 2-2-16

Cc-Form-A - Claimant'S Application For Change Of Physician And Request For Hearing

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