Form 10a - Respondent'S Response To Claimant'S Form-A Application For Change Of Physician
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1COURT OF EXISTING CLAIMS
FORM 10A
THIS SPACE FOR COURT USE ONLY
1915 NORTH STILES, STE 127
OKLAHOMA CITY, OKLAHOMA 73105-4918
Send original to
Court of Existing Claims and 1 copy to
Claimant or the Claimant’s Attorney of
Record
In re claim of:
Full Name of Injured Employee (Claimant)
Claimant’s Social Security Number (LAST 4 DIGITS ONLY)
XXX-XX-_________________________
WCC FILE NO.
Name of Respondent (Employer)
Employer’s Insurance Carrier, Permit # for Court Approved Individual Self-Insured
Date of Injury
or Own Risk Group, Uninsured
NOTE: Mediation is available to address certain workers’ compensation disputes. For information, call (918) 581-2714.
RESPONDENT’S RESPONSE TO CLAIMANT’S FORM-A APPLICATION FOR CHANGE OF PHYSICIAN
[For use ONLY if the worker is NOT subject to a Certified Workplace Medical Plan (CWMP).]
Respondent rejects the three (3) physicians named in Claimant’s Form-A Application for Change of Physician bearing a file-stamped
date of _______________, _____, and presents to claimant the following list of three (3) physicians qualified to treat the claimant’s
injured body part for which the change of physician is sought:
(1)_____________________________________________________
(2)_____________________________________________________
(3)_____________________________________________________
I declare under penalty of perjury that I have examined all statements contained herein, and to the best of my knowledge and belief, they are true,
correct and complete. ANY PERSON WHO COMMITS WORKERS’ COMPENSATION FRAUD, UPON CONVICTION, SHALL BE GUILTY OF A FELONY.
Signed this________________day of______________________,___________.
Signature of Filing Party
I HEREBY CERTIFY THAT ON THIS _______ DAY OF
______________________, _________ A COPY OF THIS FORM
Address (Number & Street)
WAS MAILED, POSTAGE PREPAID, TO:
Opposing Party/Counsel
City
State
Zip Code
Address (Number & Street)
Telephone # of Filing Party
City
State
Zip Code
Print or type name of Attorney
OBA #
Rev. 06/24/2015
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