Fillable WC003 Notice One Time Change Physician 2 (Colorado DORA)

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WC003 Notice One Time Change Physician 2 (Colorado DORA)

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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
NOTICE OF ONE-TIME CHANGE OF PHYSICIAN &
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
Claimant
Date of Injury
Claimant’s Telephone #
Insurance Carrier
Employer
Insurance Carrier Claim #
WC# (if applicable)
Most employers are required to give an employee a choice of physicians following notification that the
employee has been injured on the job. However, some employers are exempt from this requirement. Unless
you work for an employer that is exempt from this requirement,
you should have been given a written
designated provider list containing a list of at least four physicians or corporate medical providers or a
combination of both, where available. The designated provider list should also contain the name and contact
information of the respondents’ representative(s), as well as the name of the insurer or if the employer is self-
insured. Unless you work for an employer that is exempt, you are allowed a one-time change of physician,
subject to the following requirements:
1.
You must complete and sign this form. The form should be filled out as fully as possible with
all known information.
2.
This form must be provided to the respondents’ representative(s) within ninety days after the
date of the injury, and before the treating physician has determined maximum medical
improvement.
3.
The requested new physician is on the designated provider list or provides medical services for
a designated corporate medical provider on the list given to you following your injury.
4.
You are not required to provide this form to the physicians, but may do so.
Current Authorized Treating Physician:
Physician Name
Phone #
(_____)
Address
Street Address/PO Box
City
State
Zip Code
Requested Authorized Treating Physician:
Physician Name
Phone #
(_____)
Address
Street Address/PO Box
City
State
Zip Code
WC003 Rev. 06/15
Page 1 of 2
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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
By signing this form I acknowledge that I wish to make a one-time change of physician pursuant to §8-43-404(5)(a)(III)
and certify that the information provided in this form is, to the best of my knowledge and belief, true, correct and
complete.
I hereby authorize to release medical
(Name and address of current treating physician)
information relating to
,
on-the-job injury
(Claimant’s name) (Date of Injury)
to for purposes of providing medical care under the
(Name and address of requested new treating physician)
Workers’ Compensation Act.
I understand that this information may be given to my employer and also may be given to other persons necessary to
resolve my claim. All written communications to any physician or health care provider shall be simultaneously
provided to me or, if represented, to my attorney.
Without my express revocation, this consent will automatically expire upon satisfaction of the need for disclosure, but
in any event will expire 180 days from the date hereof, unless otherwise specified:
Signed: Dated:
Print Name:
CERTIFICATE OF SERVICE: Copies of this document were placed in the U.S. mail or hand-delivered to
the following parties this
day of
, .
Day Month Year
List the names and addresses of all persons copied:
Respondents’ Representative(s):
While you are not required to send this form to the physicians, see Instruction No. 4., doing so may result in a
smoother transition.
Current Authorized Treating Physician:
Requested Authorized Treating Physician:
By:
Signature
WC003 Rev. 06/15
Page 2 of 2
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WC003 Notice One Time Change Physician 2 (Colorado DORA)

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Completed 27 January 2021

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