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Workers Compensation (B0006 rev. 704) REDESIGNATION OF PHYSICIAN FORM In the event of a work related injury or illness, I request to be treated by my personal physician. I understand this designation

How to fill out predesignation of physician form

Point by point instructions on how to fill out the predesignation of physician form:

1. Obtain the form: The first step is to obtain a copy of the predesignation of physician form. You can typically find this form on your employer's website or by contacting your human resources department.
2. Personal information: Fill in your personal information accurately. This includes your full name, address, phone number, and date of birth. Ensure that all information is legible and up to date.
3. Insurance details: Provide information about your insurance coverage. This includes the name of your insurance carrier, policy number, and group number. Double-check this information to ensure accuracy.
4. Selected physician: Indicate your selected physician by filling in their complete name and contact information. This is the healthcare provider you want to treat you if you experience a work-related injury or illness.
5. Effective dates: Specify the effective date of the predesignation, which is the date when your chosen physician becomes the predesignated physician for your work-related injuries or illnesses. Be sure to follow any guidelines or limitations set by your employer or insurance carrier.
6. Signature and date: Sign and date the form. By doing so, you are acknowledging that the information provided is accurate and that you understand the implications of predesignating a physician.

Who needs predesignation of physician form?

1. Employees covered by workers' compensation insurance: If you are covered by workers' compensation insurance, it is beneficial to complete a predesignation of physician form. It allows you to select a specific healthcare provider who will provide treatment for any work-related injuries or illnesses.
2. Individuals with existing physician-patient relationships: If you already have an established relationship with a trusted physician or specialist, predesignating them as your physician for work-related injuries can ensure continuity of care and personalized treatment.
3. Those seeking control over their healthcare choices: Predesignating a physician gives you more control over your healthcare decisions in the event of a work-related injury or illness. It allows you to choose a healthcare provider who understands your medical history and preferences.

Remember, it is essential to consult your employer's specific guidelines and regulations regarding predesignation of physician forms, as they may vary.

For pdfFiller’s FAQs

What is predesignation of physician form?

Predesignation of physician form is a document that allows an employee to designate their personal physician as their primary treating physician in case of a work-related injury.

Who is required to file predesignation of physician form?

Employees who want to designate their personal physician as their primary treating physician in case of a work-related injury are required to file predesignation of physician form.

How to fill out predesignation of physician form?

To fill out predesignation of physician form, the employee must provide their personal physician's information and sign the form acknowledging their choice.

What is the purpose of predesignation of physician form?

The purpose of predesignation of physician form is to allow employees to choose their personal physician as their primary treating physician in case of a work-related injury, ensuring continuity of care.

What information must be reported on predesignation of physician form?

The information required on predesignation of physician form includes the employee's personal physician's name, address, phone number, and signature.

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