Get the free Predesignation of Physician Form

Los Angeles Unified School District Workers Compensation Program Redesignation of Physician Form In the event of a work related injury or illness, I request to be treated by my personal physician.

How to fill out predesignation of physician form

How to fill out predesignation of physician form:

1. Begin by obtaining a copy of the predesignation of physician form. This can usually be obtained from your employer or insurance company.
2. Fill in your personal information, including your name, address, and contact information.
3. Provide information about your current primary care physician, including their name, address, and contact information. This is the physician you would like to designate as your primary physician for any work-related injuries or illnesses.
4. If you wish to designate an alternative physician, provide their information as well. The alternative physician is someone you trust and would like to see if your primary care physician is not available.
5. Sign and date the form to make it legally binding.
6. Submit the completed form to your employer or insurance company as instructed.

Who needs predesignation of physician form:

1. Employees who want to have control over their medical care in the event of a work-related injury or illness may need to fill out a predesignation of physician form.
2. It is beneficial for employees who have a preferred primary care physician and want to ensure that they are the one to provide medical treatment in the case of a workplace injury.
3. Additionally, employees who have a specific alternative physician they prefer to see if their primary care physician is unavailable can also benefit from filling out this form.

For pdfFiller’s FAQs

What is predesignation of physician form?

The predesignation of physician form is a document that allows an injured worker in California to choose their own personal physician or medical group prior to a work-related injury. This form must be submitted to the employer's workers' compensation insurance carrier.

Who is required to file predesignation of physician form?

In California, any employee who wants to predesignate their personal physician or medical group as their primary treating physician in case of a work-related injury is required to file the predesignation of physician form.

How to fill out predesignation of physician form?

To fill out the predesignation of physician form, the employee must provide their personal physician's name, business address, telephone number, and California license number. The form must be signed and dated by the employee.

What is the purpose of predesignation of physician form?

The purpose of the predesignation of physician form is to allow employees to choose their own personal physician or medical group for treatment in case of a work-related injury, rather than being assigned a physician by their employer's workers' compensation insurance carrier.

What information must be reported on predesignation of physician form?

The predesignation of physician form must include the personal physician's name, business address, telephone number, and California license number. The form must also be signed and dated by the employee.

How can I edit predesignation of physician form from Google Drive?

By integrating pdfFiller with Google Docs, you can streamline your document workflows and produce fillable forms that can be stored directly in Google Drive. Using the connection, you will be able to create, change, and eSign documents, including predesignation of physician form, all without having to leave Google Drive. Add pdfFiller's features to Google Drive and you'll be able to handle your documents more effectively from any device with an internet connection.

How can I edit predesignation of physician form on a smartphone?

The pdfFiller apps for iOS and Android smartphones are available in the Apple Store and Google Play Store. You may also get the program at https://edit-pdf-ios-android.pdffiller.com/. Open the web app, sign in, and start editing predesignation of physician form.

Can I edit predesignation of physician form on an Android device?

Yes, you can. With the pdfFiller mobile app for Android, you can edit, sign, and share predesignation of physician form on your mobile device from any location; only an internet connection is needed. Get the app and start to streamline your document workflow from anywhere.