Employees Notification Of Intent To Leave State-Change Dr Or Hosp {044}

Form 044 EMPLOYEE'S NOTIFICATION OF INTENT TO LEAVE LOCALITY OR STATE, AND TO CHANGE DOCTOR OR HOSPITAL PLEASE PRINT OR TYPE NOTICE: Injured employees should contact the insurance carrier prior to making plans to leave the state for medical care. THE CARRIER MAY NOT BE LIABLE FOR ANY OR ALL OF THE COSTS. Other states are not bound by our limitations on medical fees and you may have to pay the difference between what is allowed in Utah and what the new physician charges. If you have a question as to who the carrier is, ask your employer. INCOMPLETE OR UNSIGNED FORMS WILL BE RETURNED. NO ACTION WILL BE TAKEN UNTIL THE ATTENDING PHYSICIAN'S STATEMENT (FORM 043) IS RECEIVED. ________________________________________ Name of Employer _______________________________________ Street Address of Employer _______________________________________ City, State and Zip of Employer _______________________________________ Name of Employee (Printed) _______________________________________ Utah Street Address of Employee _______________________________________ Utah City and Zip Code of Employee _______________________________________ Utah Phone # SS # __________________________________ New Address of Employee ___________________________________ New City, State and Zip Code of Employee ___________________________________ New Area Code and Phone # ____________________________________ Date of Injury __________________________________ Insurance Carrier __________________________________ Employer's Area Code and Telephone # *************************************************************************************** I left/intend to leave (circle one) the state on (date) _____________________. I have/have not (circle one) reported to my last Utah physician _____________________________________for a current examination. (Physician full name and title) _________________________________________________________________________________________________________ (Physician's complete address, including zip and office number) (Please check): The Attending Physician's Statement (Form 043) describing my condition when last examined is attached to this request. (This form will not be processed without accompanying Form 043.) The treating physician that I have chosen in my new location is: Dr. _____________________________________ _____________________________________ Name (including title) Address, Office #, City, State & Zip _____________________________________ _____________________________________ Area Code and Phone Number Employee's Signature *************************************************************************************** Receipt acknowledged by: ______________________________Date:_______________________________ Copies mailed to: _________________________________________________________________________ Mail completed form to: Utah Labor Commission ­ Industrial Accidents Division at address below. This form must accompany Form 043. Official Form 044 10/16 State of Utah * Labor Commission * Division of Industrial Accidents 160 East 300 South * P.O. Box 146610 Salt Lake City, UT 84114-6610 * Telephone: (801) 530-6800 Fax: (801) 530-6804 * Toll Free: (800) 530-5090 * www.laborcommission.utah.gov American LegalNet, Inc. www.FormsWorkFlow.com