Get the free PRE-DESIGNATED PHYSICIAN FORM FOR ON–THE-JOB INJURIES

This form is designed for employees to indicate their pre-designated physician for on-the-job injuries and for physicians to agree to provide treatment.

How to fill out pre-designated physician form for

How to fill out PRE-DESIGNATED PHYSICIAN FORM FOR ON–THE-JOB INJURIES

1. Step 1: Obtain the PRE-DESIGNATED PHYSICIAN FORM from your employer or the company's website.
2. Step 2: Read the instructions carefully to understand the form's purpose and requirements.
3. Step 3: Fill in your personal information, including your name, contact details, and employee ID.
4. Step 4: Provide details about your preferred physician, including their name, contact information, and medical license number.
5. Step 5: Sign and date the form to confirm your choice of physician.
6. Step 6: Submit the completed form to your HR department or designated personnel for processing.

Who needs PRE-DESIGNATED PHYSICIAN FORM FOR ON–THE-JOB INJURIES?

1. Employees who wish to have a specific physician treat them in case of on-the-job injuries.
2. Workers who want to ensure their medical care preferences are recognized by their employer.
3. Individuals covered by workers' compensation and seeking continuity of care with a chosen doctor.

People Also Ask about

What is a predesignation form?

Download Form. This is a form that was created by the Division of Workers' Compensation, consistent with Labor Code Section 4600(d), to allow an injured worker to predesignate a physician prior to an industrial injury. The form itself lists the requirements to be able to predesignate a physician.

What is DWC form 9783?

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 is the meaning of pre designation?

Definition of 'predesignation' 1. the action of designating in advance; an instance thereof, an advance designation. 2. logic. in the terminology of Sir William Hamilton, an indication or sign of quantity affixed to a proposition or term.

What is a pre-designation form?

Employees have the option of pre-designating their personal physician as their treating physician in the event of a work-related injury/illness. This designation must occur prior to a work-related injury/illness and your physician must agree to be pre-designated.

Who fills out the return to work form?

Employee: Have your health care provider review your attached job description and complete this form. Return the completed form to your supervisor before you return to work.

Is the first report of injury filed on the first visit the patient makes to the physician for their on the job injury?

The statement is False; the First Report of Injury is not filed during the first visit to the physician for a work-related injury. Instead, it is typically filed within 7 days of the employer learning about the injury.

What not to say to a workman's comp doctor?

Never lie about prior injuries, pre-existing conditions, or medical history. Never lie about the extent of your workplace injury or how it happened. Do not exaggerate your symptoms, including pain or functionality.

What does "personal physician" mean?

Personal physician means the employee's regular physician and surgeon who has previously directed the medical treatment of an employee and who retains the employee's medical records and history.

For pdfFiller’s FAQs

What is PRE-DESIGNATED PHYSICIAN FORM FOR ON–THE-JOB INJURIES?

The Pre-Designated Physician Form for on-the-job injuries is a document that allows an employee to choose a specific physician to provide medical care in the event of a work-related injury or illness, rather than going through the employer's designated medical provider.

Who is required to file PRE-DESIGNATED PHYSICIAN FORM FOR ON–THE-JOB INJURIES?

Employees who wish to have a pre-designated physician for their medical treatment in case of work-related injuries are required to file the Pre-Designated Physician Form.

How to fill out PRE-DESIGNATED PHYSICIAN FORM FOR ON–THE-JOB INJURIES?

To fill out the Pre-Designated Physician Form, the employee must provide their name, contact information, and details of their chosen physician, including the physician's name, address, and phone number. The form may also require the employee's signature and the date.

What is the purpose of PRE-DESIGNATED PHYSICIAN FORM FOR ON–THE-JOB INJURIES?

The purpose of the Pre-Designated Physician Form is to allow employees to have a say in their medical care in the case of a work-related injury, ensuring that they receive treatment from a trusted physician of their choice.

What information must be reported on PRE-DESIGNATED PHYSICIAN FORM FOR ON–THE-JOB INJURIES?

The Pre-Designated Physician Form must report the employee's personal information, the name and contact details of the pre-designated physician, and the employee's signature indicating consent and acknowledgement.