Form-A Order For Change Of Treating Physician
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1THIS SPACE
COURT OF EXISTING CLAIMS
Send original and 2 copies to
1915 NORTH STILES, STE 127
Court of Existing Claims
OKLAHOMA CITY, OKLAHOMA 73105-4918
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)
WCC FILE NO.
Employer’s Insurance Carrier, Permit # for Court Approved Individual Self-Insured or
Date of Injury
Own Risk Group, Uninsured
FORM-A ORDER FOR CHANGE OF TREATING PHYSICIAN
NOW on this _______ day of __________________________, __________, the Court of Existing Claims, 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
[state injured
respondent on the date above stated to the _________________________________________________________________
body part(s)]
.
THAT the claimant’s application for change of treating physician pursuant to 85 O.S., Section 326(E) 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 ___________________________________________________________
[
s
tate injured body part(s)].
IT IS FURTHER ORDERED that per 85 O.S., Section 326, the designated treating physician shall provide the claimant such
medical, diagnostic, surgical or other attendance or treatment, nurse and hospital service, medicine, crutches and apparatus as may be
reasonable and necessary after the claimant’s compensable injury to the ____________________________________________________
[state injured body part(s)]
__________________________________________________
, subject to the diagnostic testing limitation in
Official Disability Guidelines
85 O.S., Section 326(F) and treatment guidelines of the Work Loss Data Institute’s
(ODG) or Physician
Advisory Committee’s Oklahoma Treatment Guidelines (OTG), as applicable.
The respondent shall provide the designated physician with a file-stamped copy of this order.
BY ORDER OF _____________________________________________________________________
COURT OF EXISTING CLAIMS JUDGE
Signature:
Signature:
Claimant/Counsel
Employer-Respondent/Counsel
Print:
Print:
Address (Number and Street)
Address (Number and Street)
City
State
Zip
City
State
Zip
Rev. 06/24/2015
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