THESE FORMS ARE ONLY RECOMMENDED
*Date*
*Worker’s Name*
*Worker’s Address*
*Worker’s City/State/Zip*
RE:
*usual regarding information set up*
Dear *Injured Worker’s Name*:
In the State of New Mexico, the employer/insurer has the right to direct medical care. Under §52-1-49,
the employer/insurer must decide whether to choose the initial health care provider or to allow the
worker to choose the initial health care provider.
The party who makes the initial selection retains the right to continue with that doctor for the initial 60
days, after which time the other party must file a change in writing if they want to redirect the health
care under the Automatic Right of Second Selection. The forms are available at the local Workers’
Compensation Administration office or by calling toll-free 1-800-255-7965.
In this case, the employer insurer has chosen to give you (the worker) the right to choose the initial
healthcare provider for your workers’ compensation injury.
INSTRUCTION TO WORKER
Please proceed to obtain health care for your alleged work-related injury from the New Mexico
licensed health care provider of your choice. Please have your health care provider contact *NAME
OF INSURANCE COMPANY/TPA* for all authorizations, approvals and billing questions at *INSURANCE
COMPANY/TPA ADDRESS* and *INSURANCE COMPANY/TPA PHONE NUMBER*.
Please be advised that this does not mean your claim has been accepted. Payment may be made under
a reservation of right while we investigate your claim.
If you have any questions, please feel free to call me at *Adjuster phone number*. If you would like
additional information and are not represented by an attorney, feel free to call the Workers’
Compensation Administration Ombudsman Program at 1-800-255-7965.
Sincerely yours,
By:
___________________________
*, Adjuster