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Application for Expedited Hearing

One-Time Change of Authorized Treating Physician

Office of Administrative Courts

1525 Sherman, 4th Floor, Denver, CO 802032864 S Circle Dr., Suite 810, Colorado Springs, CO 80906222 S. 6th St., Suite 414, Grand Jct., CO 81501

Claimant First Name

Claimant Last Name

Employer

Respondent

Date of Injury

WC Number

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):

Claimant has requested a one-time change of physician (attach a copy)

Insurer has provided a written objection within 7 business days of the request (attach a copy);

There exists a factual dispute requiring a hearing

State below factual dispute(s) that exist:

Attach file here:

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:

Witness 1

Witness 2

Witness 3

Witness 4

Witness 5

Witness 6

Attach additional witness pages as necessary:

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

Case Name

Is the Claimant an Individual or a company?

IndividualCompany

Company

Claimant Name

First Name

Last Name

Suffix

Signature

Please type your name in the box below. By typing your name, you certify this information is accurate and certify that this will act as your binding electronic signature.

First Name

Middle Initial

Last Name

Suffix

Attorney Registration Number

Company

Address

City

State

ZIP

#####

Phone Number

###-###-####

Signature

Email Address

I am the::

Contact Preference

You have selected traditional mail as your preferred contact method. This may result in delay in receipt of any procedural or final order. If you accept these terms, please check below. If you do not, please select "Email."

I accept

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):

Opposing Party 1 or their Representative

First Name

Middle Initial

Last Name

Suffix

Company

Address

City

State

ZIP

#####

Phone Number

###-###-####

Email Address

Recipient is the:

Oppossing Party 2 or their Representative

First Name

Middle Initial

Last Name

Suffix

Company

Address

City

State

ZIP

#####

Phone Number

###-###-####

Email Address

Recipient is the:

Please type your name in the box below. By typing your name, you certify this information is accurate and certify that this will act as your binding electronic signature.

Date Served:

To attach additional recipients of this pleading, please click here.

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