Response To Petition For Change Of Physician

RESPONSE TO PETITION FOR CHANGE OF PHYSICIAN Employer Name and Address: Surety Name and Address: Telephone Number: Employee Name and Address: Telephone Number: Additional Documentation to Support Decision (circle one): No Yes Response to petition (circle one): Approved Denied Reasons for Denial: Further medical treatment is not reasonable or necessary.___________ Other (Please explain)_______________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Hearing Dates/Times Availability Next 14 Days: ___________________________________ _____________________________________________________________________________ Date: ________________ Signature: _________________________________________ Typed/Printed Name: _________________________________ Title: ______________________________________________ Original to Idaho Industrial Commission, 700 South Clearwater Lane, PO Box 83720, Boise, ID 83720-0041, or faxed to the Commission at 208-332-7558. Copy to Employee. (Rev. May 8, 2013) Response - Page 1 of 2 ­ Appendix 7B American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF SERVICE I hereby certify that on the ______ day of ___________, 20____, I caused to be served the Original Response to Petition for Change of Physician upon: Idaho Industrial Commission 700 South Clearwater Lane Post Office Box 83720 Boise, Idaho 83720-0041 via: ( ) Personal Service of Process ( ) Regular U. S. Mail ( ) Faxed to 208-332-7558 I also hereby certify that on the _____ day of ____________, 20___, I caused to be served a true and correct copy of the foregoing Response to Petition for Change of Physician upon: CLAIMANT'S NAME AND ADDRESS _________________________________________ _________________________________________ _________________________________________ via: ( ) Personal Service of Process ( ) Regular U. S. Mail ________________________________ Signature ________________________________ Print or Type Name (Rev. May 8, 2013) Response - Page 2 of 2 ­ Appendix 7B