Petition For Change Of Physician

PETITION FOR CHANGE OF PHYSICIAN Employee Name and Address: Employer Name and Address: Telephone Number: Social Security Number: Current Physician and Address: Surety Name and Address (if known): Requested Physician and Address: Additional Information or Documentation Attached (Circle One): No Yes Date of Injury/Disease: ____________________________________________________________ Medical Treatment to Date: ___________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Reason for Change: _________________________________________________________________ _________________________________________________________________________________ Hearing Date/Time Availability Next 30 Days: ___________________________________________ If the employer/surety responds that no further medical treatment is reasonable or necessary, then you must instead pursue your claim through the complaint process. You will be notified by mail if this is the case, and no hearing will be set. Date: ____________ Signature:__________________________________________________ Typed/Printed Name: ________________________________________ ORIGINAL TO EMPLOYER OR SURETY Copy to Idaho Industrial Commission, 700 South Clearwater Lane, PO Box 83720, Boise, ID 83720-0041, or fax to 208-332-7558. (Rev. May 8, 2013) Petition - Page 1 of 2 ­ Appendix 7A 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 Petition for Change of Physician upon either the following Employer or its Surety: EMPLOYER'S NAME AND ADDRESS ________________________________ ________________________________ ________________________________ OR SURETY'S NAME AND ADDRESS _________________________________ _________________________________ _________________________________ via: ( ) Personal Service of Process ( ) Regular U. S. Mail via: ( ) Personal Service of Process ( ) Regular U.S. Mail I also hereby certify that on the _____ day of ____________, 20___, I caused to be served a true and correct copy of the foregoing 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 ____________________________________ Signature ____________________________________ Typed or Printed Name (Rev. May 8, 2013) Petition - Page 2 of 2 ­ Appendix 7A American LegalNet, Inc. www.FormsWorkFlow.com