Get Application To Change Doctors - Utah Labor Commission - Utah.gov - Laborcommission Utah

Changing your healthcare provider is an important step in managing your treatment. The Application To Change Doctors from the Utah Labor Commission enables you to formally request a change. This guide provides a clear step-by-step approach to accurately complete the application online.

Follow the steps to complete your application successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the carrier file number associated with your case. This number is essential for proper identification of your claim.
3. Fill in the name of the injured person in the designated field, followed by their Social Security number to further confirm identity.
4. Provide the home address, including the street, city, state, and zip code of the injured person. Ensure accuracy for communication purposes.
5. Enter the home phone number of the injured person, so they can be contacted easily.
6. Document the date when the injury or occupational disease occurred and the employer's name, along with the full address and phone number. This information establishes the context of the claim.
7. In the section provided, briefly describe how the accident occurred, the parts of the body that were injured, and the outcomes of the injury.
8. List the names and addresses of all doctors who treated the injured person, in the order in which the treatments were received.
9. Indicate whether the current doctor was asked for a referral and provide the status of that request.
10. Specify the current doctor from whom a change is being requested. Fill in their full name, title, address, and zip code.
11. Indicate the new doctor’s full name, title, address, and zip code who is being requested as the new treating physician.
12. Provide clear reasons for wanting to change doctors, ensuring that they are concise and relevant.
13. Finally, mail the completed request to the insurance carrier or adjustor listed. Ensure the street/mailing address, city, state, and zip code are correct.
14. Once submitted, await a response. The action on your request will be noted as either approved or denied, along with any reasons for denial if applicable.
15. After processing, make sure that you receive copies of the form, whether the request is approved or denied, for your records.

Act now to complete your application online and take the next step towards your healthcare provider change.