Get the free Employee Pre-Designation of Personal Physician Form

This form allows employees to designate their personal medical physician to treat work-related injuries or illnesses, provided certain criteria are met.

How to fill out employee pre-designation of personal

How to fill out Employee Pre-Designation of Personal Physician Form

1. Obtain the Employee Pre-Designation of Personal Physician Form from your HR department or company website.
2. Read the instructions carefully to understand the requirements of the form.
3. Fill in your personal information, including your name, employee ID, and contact details.
4. Provide the name and contact information of your chosen personal physician.
5. Sign and date the form to acknowledge your choice.
6. Submit the completed form to your HR department or designated representative.

Who needs Employee Pre-Designation of Personal Physician Form?

1. Employees who wish to designate a personal physician for workers' compensation purposes.
2. Employees who have a preferred physician and want their employer to recognize them for medical treatment.
3. New employees or those changing physicians for their health care needs should complete the form.

For pdfFiller’s FAQs

What is Employee Pre-Designation of Personal Physician Form?

The Employee Pre-Designation of Personal Physician Form is a document that allows employees to choose a personal physician for worker's compensation case management, enabling them to receive medical care from a physician of their choice in the event of a work-related injury.

Who is required to file Employee Pre-Designation of Personal Physician Form?

Employees who wish to pre-designate a personal physician for their workers' compensation claims are required to file the Employee Pre-Designation of Personal Physician Form. This is typically applicable in workplaces that provide workers' compensation insurance.

How to fill out Employee Pre-Designation of Personal Physician Form?

To fill out the Employee Pre-Designation of Personal Physician Form, an employee should provide their personal information, including name and contact details, along with the information of the chosen physician, such as the physician’s name, address, and phone number, and then sign the form to confirm their selection.

What is the purpose of Employee Pre-Designation of Personal Physician Form?

The purpose of the Employee Pre-Designation of Personal Physician Form is to allow employees to select a specific physician for medical treatment in the event of a work-related injury, which helps ensure continuity of care and access to preferred medical services.

What information must be reported on Employee Pre-Designation of Personal Physician Form?

The information that must be reported on the Employee Pre-Designation of Personal Physician Form includes the employee's name, contact information, the name and contact details of the designated physician, and the employee's signature confirming the designation.