Entry Of Appearance Form (OAC)

STATE OF COLORADO OFFICE OF ADMINISTRATIVE COURTS 1525 Sherman Street, 4 th Floor, Denver, CO 80203 Fax: (303) 866 - 5909 2864 S. Circle Dr., Suite 810, Colo. Springs, CO 80906 Fax: (719) 576 - 2978 222 S. 6 th Street, Suite 414, Grand Jct., CO 81501 Fax: (970) 248 - 7341 Claimant, COURT USE ONLY vs. WC NUMBER: Employer, and DATE OF INJURY: Respondent. APPLICATION FOR EXPEDITED HEARING Complete Section A, B, C, D, E, or F. A. The Respondents have filed a Notice of Contest within the previous 45 days on (date ) and the Claimant requests an expedited hearing on compensability and medical benefits. ( You must a ttach a copy of the Notice of Contest). Section 8 - 43 - 203(1)(a), C.R.S. B. There is an urgent need for prior authorization of health care services, as recommended in writing by , an authorized treating provider, and prior authorization has been denied. (You must attach a copy of the recommendation of the authorized treating provider). The Claimant requests an expedited hearing. Rule 16 - 10, WCRP . C. The Respondents have filed a Petition to Suspend, Modify, or Terminated Compensation on (date) and the C laimant filed an objection to the Petition on (date) . The Respondents request an expedited hearing. (You must attach a copy of the Petition and objection). Rule 6-4, WCRP. D. The C laimant provided the Employer with notice of an alleged injury or injuries within the previous 45 days on (date) . The (Claimant or Respondents) request an expedited hearing on the issue of whether the Employer or Insurer provided a list of medical providers/physicians in compliance with section 8-43-404(5), C.R.S. E. The Insurer or Self - Insured Employer filed an initial admissi on of liability for the claim within the previous 45 days on (date). The (Claimant or Respondents) request an expedited hearing on the issue of whether the Employer or Insurer provided a list of medical providers/physicians in compliance with section 8-43-404(5), C.R.S. F. The Insurer or Self - Insured Employer admitted liability within the previous 45 days on (date) which included a reduction for compensation pursuant to section 8-42-112, C.R.S. (Claimant or Respondents) request an expedited hearing on the issue of whether the Employer or Insurer may reduce compensation. The opposing party may file a response to this Application for Expedited Hearing within 10 days of the mailing or delivery of this Application for Expedited Hearing. American LegalNet, Inc. www.FormsWorkFlow.com Witnesses to be called at the hearing or by deposition: List names and addresses: 1. 2. 3. 4. 5. 6. (Attach additional pages if necessary) X Signature Attorney Registration Number (if applicable) First Name MI : Last Name Suffix Company Address City State Zip Phone E - mail Signor is: I hereby certify that I mailed or delivered true and correct copies of the APPLICATION FOR EXPEDITED HEARING to all parties at the addresses shown below: (A claimant must provide a copy to the employer and the insurer, or their attorney.) : Party 1 First Name MI Last Name Suffix Company Address City State Zip Phone E - mail Recipient is the: Party 2 First Name MI Last Name Suffix Company Address City State Zip Phone E - mail Recipient is the: Signature of person serving Application Date served Rev 6/16 American LegalNet, Inc. www.FormsWorkFlow.com