Health Care Provider Disagreement Form

Rev 11.4.4.9 NMAC STATE OF NEW MEXICO WORKERS222 COMPENSATION ADMINISTRATION , WCA No.: Worker, v. , and , Employer/Insurer. HEALTH CARE PROVIDER DISAGREEMENT FORM A disagreement has arisen over the selection of Health Care Provider (HCP), or provision of health care services pursuant to 11.4.4.12 NMAC. Check the appropriate reason for the Health Care Provider disagreement. Applicant disagrees with the Notice of Change of Health Care Provider pursuant to 11.4.4.12(F)(1) or (F)(2) NMAC.: A Notice of Change of HCP was served by: Worker Employer on , 20. (Attach a copy of the Notice of Change of Health Care Provider) Applicant disagrees that the authorized HCP is providing the worker reasonable and necessary medical care and requests a change in HCP. Pursuant to 11.4.4.12(L) NMAC, the applicant bears the burden of proof to show that the worker is not receiving reasonable and necessary medical care or the request will be denied. Applicant may suggest an alternate HCP pursuant to 11.4.4.12(K)(2) NMAC: Applicant objects to the authorized HCP for the following specific reasons (11.4.4.12(K)(1) NMAC): Signature of filing party American LegalNet, Inc. www.FormsWorkFlow.com Worker222s Rep.: Address: City/State/Zip: Telephone: E-mail address for service: Worker222s Name: SSN: Date of Accident: Mailing Address: City/State/Zip: Telephone: E-mail address for service: Insurer: Address: City/State/Zip: Telephone: Employer: Address: City/State/Zip: Telephone:E-mail address for service: E-mail address for service: Employer222s Rep.: Address: City/State/Zip: Telephone: E-mail address for service: American LegalNet, Inc. www.FormsWorkflow.com