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This form is used by employees to predesignate their personal chiropractor for work-related injuries, ensuring they have a choice in their chiropractic care by filing it with their employer.
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How to fill out personal chiropractor predesignation form
How to fill out Personal Chiropractor Predesignation Form
01
Begin by downloading the Personal Chiropractor Predesignation Form from the official website.
02
Fill in your personal information, including your full name, address, and contact details.
03
Provide your insurance information, including the name of your insurance provider and policy number.
04
Indicate the reason for seeking chiropractic care in the designated section.
05
Sign and date the form to confirm the accuracy of the information provided.
06
Submit the completed form to your chiropractic clinic either in person or via email.
Who needs Personal Chiropractor Predesignation Form?
01
Individuals seeking chiropractic care who require a formal predesignation from their insurance provider.
02
Patients looking to ensure coverage for chiropractic services through their health insurance policy.
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People Also Ask about
What is the principal business code for physicians?
621111 - Offices of Physicians (except Mental Health Specialists)
What is DWC form 9783?
Personal physician includes any physician with whom the patient has an established relationship.
What does "personal physician" mean?
(e) “Personal Physician” means (1) the employee's regular physician and surgeon, licensed pursuant to Chapter 5 (commencing with section 2000) of Division 2 of the Business and Professions Code, (2) who has been the employee's primary care physician, and has previously directed the medical treatment of the employee,
What is a predesignation of a personal physician?
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.
What is the predesignation of a personal physician?
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.
What does the physician designation do mean?
A doctor of osteopathic medicine, also known as a D.O., is a fully trained and licensed doctor. A doctor of osteopathic medicine graduates from a U.S. osteopathic medical school.
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What is Personal Chiropractor Predesignation Form?
The Personal Chiropractor Predesignation Form is a document that allows an individual to designate a specific chiropractor to provide treatment in the event of a workplace injury.
Who is required to file Personal Chiropractor Predesignation Form?
Employees who wish to have pre-designated chiropractic care for work-related injuries are required to file the Personal Chiropractor Predesignation Form.
How to fill out Personal Chiropractor Predesignation Form?
To fill out the Personal Chiropractor Predesignation Form, an individual needs to provide personal information, including their name and contact details, the name of the designated chiropractor, and possibly the chiropractor's contact information and license number.
What is the purpose of Personal Chiropractor Predesignation Form?
The purpose of the Personal Chiropractor Predesignation Form is to ensure that employees can receive chiropractic care from their chosen chiropractor without unnecessary delays or complications following a workplace injury.
What information must be reported on Personal Chiropractor Predesignation Form?
The information that must be reported on the Personal Chiropractor Predesignation Form typically includes the employee's name, the designated chiropractor's name, the chiropractor's contact information, and any relevant details about the chiropractor's qualifications or licensing.
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