Form 102, Application to Change Doctors is a tool to apply for a change of doctor/s during the course of treatment while suffering from the occupational disease or injury. Read this form carefully to understand various inputs required in accordance to the requisition for a change of doctor to the Division of Industrial Accidents, Labor Commission State of Utah.
Furnish the reason/s for the requisition to change the doctor in detail for clarity about the purpose of the request. You must type or print Form 102, Application to Change Doctors for legibility. Furnish all particulars in response to various fields seeking information truthfully.
You Must
- Complete Form 102, Application to Change Doctors duly and submit to the Office of Division of Industrial Accidents, Labor Commission of Utah State.
- Mail the request to Insurance Carrier at the address referred to in Form 102, Application to Change Doctors.
- Mail the copies of the approved or denied Form 102 to the applicant as well as the doctor selected through the proceedings of the application immediately.
- Describe the accident and the nature of injury occurred due to it in detail.
- Furnish information about Doctors treating you for now and causes for requisition of change in detail.
Form 102, Application to Change Doctors requires various inputs and begin by furnishing injured person’s name followed by Carrier File Number, and Social Security Number of the injured person. Insert residence street address of the injured person then city, state, and zip code in the respective fields. Insert home phone number with area code.
Provide date of sustaining occupational disease/injury in the requested format and continue by providing name of the employer on the next line. Furnish address of the employer followed by city, state, and zip code in spaces allocated for the same. Provide the phone number of the employer in the next blank space.
Utah Application to Change Doctors (Form 102)
Specify the way the accident occurred and the consequences owing to it. Mention injuries to body parts in detail and results. Use the space to describe as much as possible to present truthful information. Provide name/s of doctor/s treating you in the order they treated you. Select your response between yes or no if you seek referral from present doctor. Provide if the referral was approved when you select yes in response to the question.
Specify the name, address, city, state, and zip code along with the designation/title of the doctor you want to change. Insert the name, address, city, state, and zip code along with the designation/title of the doctor you want to start the treatment with on the following lines. Enter the reason for seeking the change on next lines.
Insert the name of Insurance Carrier/Adjustor followed by the street/mailing address, city, state, and zip code to complete filling Form 102, Application to Change Doctors. The last portion is reserved for the decision on the requisition by officials and no inputs from you are required here.
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