STATE OF NEW MEXICO
WORKERS' COMPENSATION ADMINISTRATION
In the Matter of the Approval of:
WCA No. ______________________
as a health care provider
MOTION FOR APPROVAL OF
OUT OF STATE HEALTH CARE PROVIDER
COMES NOW
, (an injured worker) or (a payor of workers'
compensation benefits) and moves the Director for approval, pursuant to, NMSA 1978, §52-4-1(P),
of
as a health care provider.
As grounds therefore,
states:
1. The proposed health care provider, (has) (has not) previously provided services to the
injured worker in connection with worker's present injury.
2. The proposed health care provider voluntarily submits to the jurisdiction of the Workers'
Compensation Administration (WCA), as is more fully set forth in the Affidavit attached hereto.
3. The proposed health care provider (has) (has not) previously applied to the Director of the
WCA for approval as a health care provider in this or any other case. If so, please supply name of
injured worker and injury date of the most recent application for approval.
4.
has not sought approval of this proposed health care
provider prior to the rendering of services for the following reasons:
5. Concurrence of interested parties and counsel was
.
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Out of State Health Care Provider
WHEREFORE,
respectfully requests the Director approve,
pursuant to NMSA 1978, §52-4-1(P)
as a health care
provider.
____________________________________
Signature
____________________________________
(Representative) (Attorney)
____________________________________
Address
____________________________________
City/State/Zip
____________________________________
Telephone
CERTIFICATE OF MAILING
I certify that the foregoing Motion was mailed to: ______________________________
at:
on this
day of
, 20___.
____________________________________
Calendar Clerk
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Out of State Health Care Provider
STATE OF NEW MEXICO
WORKERS' COMPENSATION ADMINISTRATION
In the matter of the approval of
WCA No. _______________________
AFFIDAVIT
1. I, being duly sworn or affirmed, state: I am licensed as a
State of
, in the
, and my license to practice is currently in good standing;
2. I agree to be bound by the schedule of maximum allowable payments and schedule of nonclinical fees currently in force and effect in New Mexico;
3. I agree to be bound by all Workers' Compensation Administration (WCA) rules and
regulations and by the Workers' Compensation Act of the State of New Mexico;
4. I agree to cooperate with the current and any successor medical cost containment
contractors engaged by the WCA pursuant to statute;
5. (I irrevocably designate
as my New Mexico agent
name, if agent
for service of process in this cause) or (I agree to accept service of process by mail in this cause);
6. I agree to honor any subpoena or notice of deposition served upon me in the manner set
forth above and to appear, if required by the Workers' Compensation Administration, in New Mexico
for all depositions and hearings, or appear telephonically at all depositions and hearings with the
permission of the Court;
7. I submit to the personal jurisdiction of the WCA and any of the New Mexico courts of
competent jurisdiction for purposes of any Workers' Compensation matter;
8. I state here that I understand that the designation as a health care provider applies only to
Revised 12/5/13
Out of State Health Care Provider
the injuries sustained by
about
in an incident alleged to have occurred on or
, and that I understand that I have no authority to refer this patient to
another health care provider who is not licensed by the State of New Mexico;
9. I understand that my designation as a health care provider can be revoked, suspended or
conditioned, by written order of the Director of the WCA, at any time, with or without cause; and;
10. I understand that if my license to practice in
is suspended or revoked, my
designation as an approved health care provider is automatically revoked, with or without notice by
the Director of the Workers' Compensation Administration.
____________________________________
Signature
____________________________________
Health Care Provider
____________________________________
Address
____________________________________
City/State/Zip
____________________________________
Telephone
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Out of State Health Care Provider
ACKNOWLEDGMENT
STATE OF
COUNTY OF
)
) ss.
)
Subscribed and sworn or affirmed to before me this
day of
,
20____.
____________________________________
Notary Public
My commission expires:
____________________
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Out of State Health Care Provider
STATE OF NEW MEXICO
WORKERS' COMPENSATION ADMINISTRATION
In the Matter of the Approval of:
WCA No. _________________
ORDER FOR APPROVAL OF
OUT OF STATE HEALTH CARE PROVIDER
THIS MATTER coming before the Director, pursuant to NMSA 1978, §52-4-1(P), and
having reviewed the Motion and Affidavit of the proposed health care provider; the Director FINDS;
1. The proposed health care provider is licensed in the State of
.
2. The proposed health care provider has given assurances in the form of an affidavit to the
Director, that his/her authorization to act as a health care provider in this particular case will not
unduly disrupt the operation of the workers' compensation system in the state of New Mexico.
3. Subject to the conditions set forth in the Affidavit, provisions concerning health care
provider choice, and the determination of the Workers' Compensation Judge concerning
admissibility and credibility of testimony, good cause exists to approve
as a health care provider with respect to the injuries of
allegedly sustained on or about
,
,
.
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Out of State Health Care Provider
IT IS THEREFORE ORDERED that, subject to the terms and conditions in the Affidavit
of the proposed health care provider; incorporated herein as if fully set forth,
is approved as a health care provider pursuant to NMSA 1978,
§52-4-1(P) for treatment of the injuries of
or about
,
allegedly sustained on
, provided however, that nothing in this Order shall be
construed to affect, in any way, the rights and obligations of the parties pursuant to statutory
provisions and promulgated rules concerning health care provider choice; and that nothing in this
Order shall be construed to affect, in any way, the acceptance or admissibility of the testimony of any
health care provider by any Workers' Compensation Judge or the credibility or weight to be ascribed
to such testimony by the Workers' Compensation Judge.
______________________________
DARIN A. CHILDERS
WCA Director
Approved as to form:
_________________________________________
<Name>, injured Worker
_________________________________________
<Name>, payor of workers' compensation benefits
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Out of State Health Care Provider