Application for Expedited Hearing One-Time Change of Authorized Treating Physician

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Vs





WC #-###-###-##
Application for Expedited Hearing One-Time Change of Authorized Treating Physician

An Expedited Hearing is requested pursuant to Rule 8-5(C), Workers’ Compensation Rules of Procedure (check all that apply): 




The opposing party may file a response to this Application for Expedited Hearing within 10 days of the mailing or delivery of this Application for Expedited Hearing. 


Witnesses to be called at the hearing or by deposition: List names and addresses: 








The Office of Administrative Courts to set this case for hearing and will send notice to the parties.  


Case Name


Claimant Name




Signature











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Certificate of Mailing

I hereby certify that I mailed or delivered the original of the Application for Expedited Hearing One-Time Change of Authorized Treating Physician to all parties at the addresses shown below (A claimant must provide a copy to the employer and the insurer, or their attorney):

Claimant/Respondent or their Representative









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Employer or their Representative









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Other









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