Approval Of Out Of State Provider

ORDER GRANTING APPROVAL OF OUT OF STATE HEALTH CARE PROVIDER. This form is used to request approval for an out-of-state healthcare provider to treat a worker within New Mexico's workers' compensation system. It is issued by the New Mexico Workers' Compensation Administration (WCA) to verify that the healthcare provider meets licensing and regulatory standards in their home state, and that their services will not disrupt the New Mexico workers' compensation system. The approval grants the out-of-state provider the right to treat the worker in question, subject to New Mexico’s laws and fee schedules. The form also outlines conditions under which this approval can be revoked or suspended. www.FormsWorkflow.com