Form Cc-Form-9 - Request For Hearing - Oklahoma Workers' Compensation Commission
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1CC-FORM-9
WORKERS’ COMPENSATION COMMISSION
THIS SPACE FOR COMMISSION USE ONLY
1915 NORTH STILES AVENUE STE 231
OKLAHOMA CITY, OKLAHOMA 73105
Send original to:
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)
REQUEST FOR HEARING
XXX-XX-________________________
Name of Employer (Respondent)
Commission File Number
Employer’s Insurance Carrier, Permit # for Commission Approved Individual Self-Insured or
Date of Injury
Group Self-Insurance Association
NOTE: Mediation is available to help resolve certain workers’ compensation disputes. For information, call (405) 522-5308 or In-State Toll Free (855) 291-3612.
(Please Type or Print)
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.
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.
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.
Signed this ____________day of_________________________________,___________.
Signature of □ Respondent □ Claimant □ Provider □ Counsel for Requestor
I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO:
Opposing Party/Counsel
Address (Number & Street)
Address (Number & Street)
City
State
Zip Code
City
State
Zip Code
Telephone # of Filing Party
Print or type Name of Attorney
OBA #
Revised 2-2-16
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