Cc-Form-A - Order For Change Of Treating Physician
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1THIS SPACE FOR COMMISSION USE ONLY
WORKERS’ COMPENSATION COMMISSION
Send original and 2 copies to
1915 NORTH STILES AVENUE STE 231
Workers’ Compensation Commission
OKLAHOMA CITY, OKLAHOMA 73105
In re Claim of:
Full Name of Claimant (Injured Employee)
Claimant’s Social Security Number (LAST 4 DIGITS ONLY)
XXX-XX-_____________________________
Name of Employer (Respondent)
COMMISSION FILE NO.
Employer’s Insurance Carrier, Permit # for Commission Approved Individual Self-
Date of Injury
Insured or Own Risk Group, Uninsured
CC-FORM-A ORDER FOR CHANGE OF TREATING PHYSICIAN
NOW on this _______ day of __________________________, __________, the Workers’ Compensation Commission, being
well and fully advised in the premises, FINDS AND ORDERS AS FOLLOWS:
THAT the claimant is not covered by a Certified Workplace Medical Plan.
THAT the respondent admits claimant sustained a compensable injury arising out of and in the course of employment with
respondent on the date above stated to the _________________________________________________________________ [state injured
body part(s)].
THAT the claimant’s application for change of treating physician pursuant to 85A O.S., §56(B) is proper and hereby granted.
IT IS THEREFORE ORDERED that Dr. _______________________________________________________ is designated as
the claimant’s treating physician for treatment of the claimant’s ___________________________________________________________
[state injured body part(s)].
IT IS FURTHER ORDERED that per 85A O.S., §50, the designated treating physician shall provide the claimant such medical,
surgical, hospital, optometric, podiatric, and nursing services, crutches and other apparatus as may be reasonably necessary in connection
with the injury to the ____________________________________________________________________________________________
[state injured body part(s)], received by the employee, subject to the diagnostic testing limitation in 85A O.S., §50(C), the Workers’
Compensation Commission’s closed formulary pursuant to Commission Rule 810:15-5-2, and treatment guidelines of the Official
Disability Guidelines published by the Work Loss Data Institute or Physician Advisory Committee Guidelines (PACG) and protocols, if
applicable as provided by law.
The employer/respondent shall provide the designated physician with a file-stamped copy of this order.
BY ORDER OF _____________________________________________________________________
WORKERS’ COMPENSATION COMMISSION ADMINSTRATIVE LAW JUDGE
Signature:
Signature:
Claimant/Counsel
OBA#
Employer-Respondent/Counsel
OBA#
Print:
Print:
Address (Number and Street)
Address (Number and Street)
City
State
Zip
City
State
Zip
Revised 2-2-16
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