Transfer of Attending Provider Form for Self Insured Workers

Transfer of Attending Provider Form for Self Insured Workers - (Forms/Publications)
Document Information
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Title Transfer of Attending Provider Form for Self Insured Workers (48 KB DOC)
Description

This form is used by self-insured injured workers who want to transfer their medical care.  Self-insured workers should complete the form and send it to their employer or their Third Party Representative.

Detail
Form number F207-114-000
Availability
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Keywords attending doctor, attending provider, change doctor, doctor, provider, self insurance, transfer, transfer of care, Transfer of Care
Languages English , Spanish
Valid dates 11-2012
Contact information Self-Insurance

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