Fillable New-hire-predesig-personal-dr Employee Pre-designation of Personal Physician

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New-hire-predesig-personal-dr Employee Pre-designation of Personal Physician

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CALIFORNIA STATE UNIVERSITY, CHANNEL ISLANDS
Employee Pre-designation of Personal Physician
The California Labor Code grants an employee, who has sustained an occupational injury or illness the
right to medical care. Labor Code Section 4600 permits you, the employee, the right to be treated by
your personal medical doctor (M.D.) or doctor of osteopathic medicine (D.O.) if the treating physician
meets the following criteria:
1. Your employer offers group health coverage.
2. The doctor is your regular physician, who shall be either a physician who has
limited his or her practice of medicine to general practice or who is a board-
certified or board-eligible internist, pediatrician, obstetrician-gynecologist, or
family practitioner, and has previously directed your medical treatment, and
retains your medical records.
3. Prior to the injury your doctor agrees to treat you for work injuries or illnesses.
4. Prior to the injury you have provided your employer the following in writing:
a. Notice that you want your personal doctor to treat you for a work-related injury
or illness.
b. You provide your personal doctor’s name and business address.
If you wish to DECLINE designating a personal physician, please provide the information requested
below.
EMPLOYEE: I, _________________________________, decline to designate a personal physician.
Employee signature: _______________________________ Dept. _______________________.
Date: _____________
If you wish to pre-designate a personal physician, please have your physician provide the information
requested below.
EMPLOYEE:
I, _________________________________, request to be treated by my personal
physician in case of an occupation injury or illness occurring during the course of my emplo
yment with
CSU, Channel Islands.
My personal physician is: _______________________________________________________
Employee signature: _______________________________ Dept: _______________________
Date: _____________
PHYSICIAN: If you agree to be the pre-designated personal physician to treat work related injuries
sustained by an employee of California State University Channel Islands, please provide the following
information. This form may be returned to the employee requesting your acceptance of pre-designation
or mailed directly to the office listed below.
I am the employee’s regular or primary care physician and I meet all of the above criteria. I agree to be
the pre-designated personal physician for ______________________________________________.
Employee’s Name
Physician Name:___________________________________ Phone: ____________________
Physician
Address:_____________________________________________________________________
Physician Signature:_________________________________ Date:______________________
Please return this form to CSU, Channel Islands, Human Resources Programs, Worker’s Comp.
Office, One University Drive, Camarillo, CA 93012
© Sedgwick CMS 2014
Page
5
NOTICE OF PERSONAL CHIROPRACTOR OR PERSONAL ACUPUNCTURIST
If your employer or your employer’s insurer does not have a Medical Provider Network, you may be able to
change your treating physician to your personal chiropractor or acupuncturist following a work-related injury or
illness. In order to be eligible to make this change, you must give your employer the name and business
address of a personal chiropractor or acupuncturist in writing prior to the injury or illness. Your claims
administrator generally has the right to select your treating physician within the first 30 days after your
employer knows of your injury or illness. After your claims administrator has initiated your treatment with
another doctor during this period, you may then, upon request, have your treatment transferred to your
personal chiropractor or acupuncturist. Chiropractors may not continue as the primary treating physician after
24 visits.
Note: If your date of injury is January 1, 2004 or later, a chiropractor cannot be your treating physician after
you have received 24 chiropractic visits unless your employer has authorized additional visits in writing. The
term “chiropractic visit” means any chiropractic office visit, regardless of whether the services performed involve
chiropractic manipulation or are limited to evaluation and management. Once you have received 24 visits, if
you still require medical treatment, you will have to select a new physician who is not a chiropractor. This
prohibition shall not apply to visits for postsurgical physical medicine visits prescribed by a surgeon, or physician
designated by the surgeon, under the postsurgical component of the Division of Workers’ Compensation’s
Medical Treatment Utilization Schedule.
You may use this form to notify your employer of your personal chiropractor or acupuncturist.
Your Chiropractor or Acupuncturist’s Information:
(name of chiropractor or acupuncturist)
(street address, city, state, ZIP)
(telephone number)
Employee Name (please print): _____________________________________________________
Employee’s Address: _____________________________________________________________
Employee’s Signature: ________________________________________________________ Date: _________
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New-hire-predesig-personal-dr Employee Pre-designation of Personal Physician

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Completed 16 February 2020

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