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NOTICE OF REDESIGNATION OF PERSONAL PHYSICIAN Employee: Complete this section. To: (name of employer) If I have a work related injury or illness, l choose to be treated by: (name of doctor)(M.D.,
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How to fill out Notice of Predesignation of:

01
First, download the Notice of Predesignation form from the appropriate source, such as your employer's website or the Department of Industrial Relations website.
02
Fill in your personal information section, which typically includes your full name, address, contact information, and employee identification number if applicable.
03
In the next section, provide the name of your chosen predesignated personal physician. This should be a physician you want to treat you in case of a work-related injury or illness. Include their full name, address, and contact information.
04
Indicate the date of predesignation by either selecting an available date from a provided calendar or by manually entering the date.
05
If you have a Managed Care Organization (MCO) contracted by your employer, indicate this by checking the appropriate box and provide the MCO's name and contact information.
06
Read carefully through any additional instructions or requirements listed on the form and make sure you comply with all of them.
07
Sign and date the completed Notice of Predesignation form.

Who needs Notice of Predesignation of:

01
All employees who wish to predesignate their personal physician in the event of a work-related injury or illness.
02
This notice is particularly essential for employees who want to have their preferred doctor provide medical treatment if they experience a work-related health issue.
03
Employees who do not predesignate their personal physician may have their medical treatment directed by their employer or the employer's workers' compensation insurance carrier.
Note: It is advisable to consult your employer or a legal professional to ensure you are following the specific guidelines and requirements set forth by your state's workers' compensation laws.
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Notice of predesignation of is a form used to designate a personal physician or medical group for an injured worker to treat work-related injuries or illnesses.
Employers are required to provide employees with the notice of predesignation of form.
The form must be completed with the designated personal physician or medical group's information and signed by the employee.
The purpose of the notice of predesignation of form is to allow injured workers to choose their own personal physician or medical group for treating work-related injuries.
The notice of predesignation of form must include the name, address, and contact information of the designated personal physician or medical group.
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2007 California PREDESIGNATION predesignated 9783-March illnessl DWC pursuant Optional documentation

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