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:
your employer offers group health coverage;
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;
your "personal physician" may be a medical group if it is a single corporation or
partnership composed of licensed doctors 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 doctor 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.
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:
Physician: I agree to this Predesignation:
(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).
Title 8, California Code of Regulations, section 9783.
(Optional DWC Form 9783 March 1, 2007 )