Appendix 7B - Response to Petition for Change of Physician

RESPONSE TO PETITION FOR CHANGE OF PHYSICIAN Employer Name and Address: Telephone Number: Surety Name and Address: Telephone Number: Employee Name and Address: Additional Documentation to Support Decision (circle one): No  Yes  Response to petition (circle one): Approved Denied Reasons for Denial:  Further medical treatment is not reasonable or necessary.___________  Other (Please explain)_______________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Hearing Dates/Times Availability Next 14 Days: ___________________________________ _____________________________________________________________________________ Date: ________________ Signature: _________________________________________ Typed/Printed Name: _________________________________ Title: ______________________________________________ Original to Idaho Industrial Commission, PO Box 83720, Boise, ID 83720-0041, or faxed to the Commission at 208-332-7558. Copy to Employee. (Rev. August 12, 2019) Response - Page 1 of 2 – Appendix 7B

CERTIFICATE OF SERVICE I hereby certify that on the ______ day of ___________, 20____, I caused to be served the Original Response to Petition for Change of Physician upon: Idaho Industrial Commission Post Office Box 83720 Boise, Idaho 83720-0041 via: ( ) Personal Service of Process ( ) Regular U. S. Mail ( ) Faxed to 208-332-7558 I also hereby certify that on the _____ day of ____________, 20___, I caused to be served a true and correct copy of the foregoing Response to Petition for Change of Physician upon: CLAIMANT’S NAME AND ADDRESS _________________________________________ _________________________________________ _________________________________________ via: ( ) Personal Service of Process ( ) Regular U. S. Mail ________________________________ Signature ________________________________ Print or Type Name (Rev. August 12, 2019) Response - Page 2 of 2 – Appendix 7B