THIS SPACE FOR COMMISSION USE ONLY
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)
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
Claimant’s Address (Number and Street)
Signature of Attorney for Claimant
Claimant’s Attorney’s Address (Number and Street)
Claimant’s Telephone Number
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:
Address (Number and Street)
Address (Number and Street)
Signature of Claimant or Claimant’s Attorney, if any