Notice Of Intent To Change Health Care Provider {8}

Mail to: Insurance Carrier Name: Insurance Carrier Address: Insurance Carrier City/State/Zip: Insurance Carrier Adjuster: DOL Form 8 Rev. 9/11 State File No. Ins. Co. File No. Date of Injury NOTICE OF INTENT TO CHANGE HEALTH CARE PROVIDER Note: An employee has the right to change health care providers from the one suggested or assigned to them by their employer, regardless of the reasons for the change, at any time during the course of treatment after the first appointment. Employee Name: Address: City/State/Zip: E-mail Address: Home Telephone: Work Telephone: I am changing my medical care for my work-related injury from the first treating health care provider selected by my employer to the provider of my choice. FIRST TREATING PROVIDER Name: Address: City/State/Zip: I am changing because: NEW TREATING PROVIDER Name: Address: City/State/Zip: I would rather treat with my family health care provider. I believe another health care provider is better able to treat my symptoms. I have previously treated with another health care provider. Other (please describe below): This notice should be presented to the employer/insurance carrier prior to changing health care providers to fulfill the requirements of Vermont law, [21 V.S.A. § 640(b)]. Notice is not required for subsequent changes of provider after the first change of provider form is submitted. Print Employee Name Employee Signature Date Workers' Compensation Division, PO Box 488, Montpelier, VT 05601-0488 American LegalNet, Inc. www.FormsWorkFlow.com