Motion state form 2026

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The document outlines the process for the approval of an out-of-state health care provider by the New Mexico Workers' Compensation Administration. It includes a motion for approval, an affidavit from the proposed provider affirming their qualifications and compliance with New Mexico regulations, and an order from the WCA Director granting approval based on specific findings. The document emphasizes adherence to state laws and the conditions under which the provider may operate.

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Click ‘Get Form’ to open the motion state form in the editor.
Begin by filling in the WCA number at the top of the form. This is essential for tracking your submission.
In the section labeled 'COMES NOW', specify whether you are an injured worker or a payor of workers' compensation benefits.
Provide the name of the proposed health care provider and indicate if they have previously provided services to the injured worker.
Complete the affidavit section, ensuring that all statements regarding licensing and compliance with New Mexico regulations are accurately filled out.
Sign and date the form at the bottom, including your address and contact information for any follow-up.
Finally, certify mailing by filling in details about where you sent this motion, ensuring all parties are informed.

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