Get Ut 102 2019-2026

The UT 102 form is an application to change doctors for individuals who have sustained an injury or occupational disease. This guide provides clear, step-by-step instructions on how to fill out the UT 102 online, ensuring a smooth and efficient process.

Follow the steps to complete the UT 102 application effectively.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. In the first section, enter the carrier file number, the name of the injured person, social security number, and home address including street, city, state, and zip code.
3. Provide the home phone number for contact purposes.
4. In the section regarding the injury, fill in the date of the injury and the name and address of the employer, including their phone number.
5. Briefly describe how the accident occurred, noting the parts of the body that were injured and any results from the incident.
6. List the names and addresses of all doctors who have treated the individual in the order they were seen.
7. Indicate whether you asked the present doctor for a referral by selecting 'Yes' or 'No'.
8. If applicable, specify the name of the current doctor and the name of the new doctor you wish to change to, providing their full names, titles (M.D., D.C., etc.), and their addresses.
9. State your reasons for wanting to change doctors in the provided space.
10. Send this completed request to the relevant insurance carrier or adjustor at their designated mailing address.
11. Once you have filled out all sections and provided necessary details, save the changes. You can then download, print, or share the form as needed.

Start filling out the UT 102 online and ensure your request to change doctors is filed efficiently.