Form A - Claimant'S Application For Change Of Physician And Request For Hearing
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1THIS SPACE FOR COURT USE ONLY
FORM A
COURT OF EXISTING CLAIMS
1915 NORTH STILES, STE 127
Send original to
OKLAHOMA CITY, OKLAHOMA 73105-4918
Court of Existing Claims 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)
WCC FILE NO.
Employer’s Insurance Carrier, Permit # for Court Approved Individual Self-Insured
Date of Injury
or Own Risk Group, Uninsured
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 85 O.S., Section 326(E), 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.
The limit set forth in 85 O.S., §326(E) of no more than two changes of physician per claim, regardless of the number of body parts
injured, will not be exceeded if this application for change of physician is allowed.
3.
A change of physician is sought for treatment of claimant’s _______________________________________(state injured body
part), for which authorized medical care has been provided for one hundred eighty (180) days prior to the date of filing this
Application.
4.
The name of claimant’s current treating physician for the injured body part is __________________________________________.
5.
Claimant presents to the employer/respondent the following list of three (3) physicians qualified to treat the claimant’s injured body
part for which a change of physician is sought:
(1)________________________________(2) ________________________
(3) _____________________________________________.
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.
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 instrument was mailed, postage
prepaid to:
Opposing Party/Counsel
Opposing Party/Counsel
Address (Number and Street)
Address (Number and Street)
City
State
Zip
City
State
Zip
_________________________________________________________________________________
Signature of Claimant or Claimant’s Attorney, if any.
Rev. 06/24/2015
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