Dol Form 8 - Notice Of Intent To Change Health Care Provider printable pdf download

Dol Form 8 - Notice Of Intent To Change Health Care Provider

DOL Form 8 Rev. 9/11

Mail to:

Insurance Carrier Name:

State File No.

Insurance Carrier Address:

Ins. Co. File No.

Insurance Carrier City/State/Zip:

Date of Injury

Insurance Carrier Adjuster:

NOTICE OF INTENT TO CHANGE HEALTH CARE PROVIDER

Note: An employee has the right to change health care providers from the one suggested or assigned to them by

their employer, regardless of the reasons for the change, at any time during the course of treatment after the

first appointment.

Employee Name:

Address:

City/State/Zip:

Home Telephone:

E-mail Address:

Work Telephone:

I am changing my medical care for my work-related injury from the first treating health care provider selected

by my employer to the provider of my choice.

FIRST TREATING PROVIDER

NEW TREATING PROVIDER

Name:

Address:

City/State/Zip:

I am changing because:

I would rather treat with my family health care provider.

I believe another health care provider is better able to treat my symptoms.

I have previously treated with another health care provider.

Other (please describe below):

This notice should be presented to the employer/insurance carrier prior to changing health care providers to

fulfill the requirements of Vermont law, [21 V.S.A. § 640(b)]. Notice is not required for subsequent changes of

provider after the first change of provider form is submitted.

Print Employee Name

Employee Signature

Date

Workers’ Compensation Division, PO Box 488, Montpelier, VT 05601-0488

Dol Form 8 - Notice Of Intent To Change Health Care Provider