Application To Change Doctors {102}

Form 102 APPLICATION TO CHANGE DOCTORS PLEASE PRINT OR TYPE ________________________________________ Name of Injured Person Carrier File No. _______________________________ Social Security No. ___________________________ ____________________________________________ Home Phone Number ________________________________________ Home Address (street) ________________________________________ City/State/Zip On ____________________, 20 _____, I sustained an injury/occupational disease arising out of and in the course of my employment at______________________________________________________________ Employer Name _____________________________________________________________________________________________________ Employer Address _______________________________________________________________________________________________________ City/ State/ Zip Phone Number Briefly describe how accident occurred, parts of body injured, and results ___________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ I have been treated by the following doctors (Give full names and addresses in the order in which they were seen):___________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ I asked my present doctor for a referral. Yes _____ No _____Referral was approved. Yes No ____ I would like permission to change from Dr. ___________________________________________________ _______________________________________________________________________________________ (Give full name, title [M.D., D.C., etc.], address and zip) To Dr. _________________________________________________________________________________ (Give full name, title [M.D., D.C., etc.], address and zip) My reasons for wanting to change are _______________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ MAIL THIS REQUEST TO: Insurance Carrier/Adjustor ________________________________________ Street or Mailing Address ________________________________________ City, State, Zip ________________________________________________ ACTION ON REQUEST Approved by: ______________________________ Date:_______________________________________ Denied by: _________________________________ Date:_______________________________________ Reasons for denial: ______________________________________________________________________ ______________________________________________________________________________________ *** Copies of this form approved or denied, must be mailed promptly to the applicant and to the doctor the applicant has requested to be the treating physician. Official Form 102 Revised 10/14 State of Utah * Labor Commission * Division of Industrial Accidents 160 East 300 South * P.O. Box 146610 Salt Lake City, UT 84114-6610 * Telephone: 801530-6800 * Fax: 801-530-6804 * Toll Free: (800) 530-5090 * www.laborcommission.utah.gov American LegalNet, Inc. www.FormsWorkFlow.com