PREDESIGNATION OF PERSONAL PHYSICIAN
In the event you sustain an injury or illness related to your employment, you may be treated for such injury or illness
by your personal medical doctor (M.D.), doctor of osteopathic medicine (D.O.) or medical group if:
• on the date of your work injury you have health care coverage for injuries or illnesses that are not work
related;
• the d
octor 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;
• your “personal physician” may be a medical group if it is a single corporation or partnership composed of
licensed do
ctors of medicine or osteopathy, which operates an integrated multispecialty medical group
providing comprehensive medical services predominantly for nonoccupational illnesses and injuries;
• prior to the injury your doctor agrees to treat you for work injuries or illnesses;
• prior to the injury you provided your employer the following in writing: (1) notice that you want your
personal doc
tor to treat you for a work-related injury or illness, and (2) your personal doctor's name and
business address.
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of
osteopathic
medicine treat you for a work-related injury or illness and the above requirements are met.
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN
Employee: Complete this section.
To: ____________________________ (name of employer) If I have a work-related injury or illness, I choose to be
treated by:
_____________________________________________________________________________________________
__________
__________________________________________________________
(name
of doctor)(M.D., D.O., or medical group)
(street address, city, state, ZIP)
_____________
_____________________________________(telephone number)
________________
________
_____________________________________________________________________
_____________________________________________________________________________________________
Employee Name (please print):
Employee's Address:
Name of Insurance Company, Plan, or Fund providing health coverage for nonoccupational injuries or illnesses:
Employee's Signature ________________________________Date: __________
Physician: I agree to this Predesignation:
Signature: _________________ _________________
__________Date: __________
(Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form, however, if the physician or designated employee of the physician or
medical group does not sign, other documentation of the physician's agreement to be predesignated will be required
pursuant to Title 8, California Code of Regulations, section 9780.1(a)(3).
July 2014
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
