DOL Form 8 "Notice of Intent to Change Health Care Provider" - Vermont

What Is DOL Form 8?

This is a legal form that was released by the Vermont Department of Labor - a government authority operating within Vermont. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2011;
  • The latest edition provided by the Vermont Department of Labor;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DOL Form 8 by clicking the link below or browse more documents and templates provided by the Vermont Department of Labor.

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Download DOL Form 8 "Notice of Intent to Change Health Care Provider" - Vermont

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DOL Form 8 Rev. 9/11
Mail to:
Insurance Carrier Name:
State File No.
Insurance Carrier Address:
Ins. Co. File No.
Insurance Carrier City/State/Zip:
Date of Injury
Insurance Carrier Adjuster:
NOTICE OF INTENT TO CHANGE HEALTH CARE PROVIDER
Note: An employee has the right to change health care providers from the one suggested or assigned to them by
their employer, regardless of the reasons for the change, at any time during the course of treatment after the
first appointment.
Employee Name:
Address:
City/State/Zip:
Home Telephone:
E-mail Address:
Work Telephone:
I am changing my medical care for my work-related injury from the first treating health care provider selected
by my employer to the provider of my choice.
FIRST TREATING PROVIDER
NEW TREATING PROVIDER
Name:
Name:
Address:
Address:
City/State/Zip:
City/State/Zip:
I am changing because:
I would rather treat with my family health care provider.
I believe another health care provider is better able to treat my symptoms.
I have previously treated with another health care provider.
Other (please describe below):
This notice should be presented to the employer/insurance carrier prior to changing health care providers to
fulfill the requirements of Vermont law, [21 V.S.A. § 640(b)]. Notice is not required for subsequent changes of
provider after the first change of provider form is submitted.
Print Employee Name
Employee Signature
Date
Workers’ Compensation Division, PO Box 488, Montpelier, VT 05601-0488
DOL Form 8 Rev. 9/11
Mail to:
Insurance Carrier Name:
State File No.
Insurance Carrier Address:
Ins. Co. File No.
Insurance Carrier City/State/Zip:
Date of Injury
Insurance Carrier Adjuster:
NOTICE OF INTENT TO CHANGE HEALTH CARE PROVIDER
Note: An employee has the right to change health care providers from the one suggested or assigned to them by
their employer, regardless of the reasons for the change, at any time during the course of treatment after the
first appointment.
Employee Name:
Address:
City/State/Zip:
Home Telephone:
E-mail Address:
Work Telephone:
I am changing my medical care for my work-related injury from the first treating health care provider selected
by my employer to the provider of my choice.
FIRST TREATING PROVIDER
NEW TREATING PROVIDER
Name:
Name:
Address:
Address:
City/State/Zip:
City/State/Zip:
I am changing because:
I would rather treat with my family health care provider.
I believe another health care provider is better able to treat my symptoms.
I have previously treated with another health care provider.
Other (please describe below):
This notice should be presented to the employer/insurance carrier prior to changing health care providers to
fulfill the requirements of Vermont law, [21 V.S.A. § 640(b)]. Notice is not required for subsequent changes of
provider after the first change of provider form is submitted.
Print Employee Name
Employee Signature
Date
Workers’ Compensation Division, PO Box 488, Montpelier, VT 05601-0488