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This form allows an employee to designate a personal physician to treat them immediately following an industrial injury, in accordance with Labor Code Section 4600.

How to fill out employee predesignated treating physician

How to fill out EMPLOYEE PREDESIGNATED TREATING PHYSICIAN NOTIFICATION FORM

1. Obtain the EMPLOYEE PREDESIGNATED TREATING PHYSICIAN NOTIFICATION FORM from your employer or HR department.
2. Fill in the employee's name, employee ID, and department at the top of the form.
3. Provide details of the preferred treating physician, including their name, address, and contact information.
4. Indicate the nature of the injury or condition that requires treatment.
5. Sign and date the form to verify the information is correct.
6. Submit the completed form to the designated HR representative or appropriate department.

Who needs EMPLOYEE PREDESIGNATED TREATING PHYSICIAN NOTIFICATION FORM?

1. Employees who are injured at work and wish to designate a specific treating physician.
2. Employers who need to keep track of predesignated treating physicians for their employees.
3. HR departments responsible for managing workers' compensation claims and treatment processes.

People Also Ask about

What is the meaning of personal physician?

Personal physician means the physician indicated on the patient's medical record as being responsible for the medical care of that patient; View Source.

What is another name for a personal physician?

Primary care practitioner () family medicine practitioner. nurse practitioner. physician assistant. internist.

What does predesignation of personal physician mean?

prior to the injury your doctor agrees to treat you for work injuries or illnesses; • prior to the injury you provided your employer the following in writing: (1) notice that you want your personal doctor to treat you for a work-related injury or illness, and (2) your personal doctor's name and business address.

What is a physician return to work release form?

A physician release form is used to show an employer that an employee is fit to return to work after a period of illness or injury.

For pdfFiller’s FAQs

What is EMPLOYEE PREDESIGNATED TREATING PHYSICIAN NOTIFICATION FORM?

The EMPLOYEE PREDESIGNATED TREATING PHYSICIAN NOTIFICATION FORM is a document used by employees to designate a treating physician for any work-related injuries or illnesses before they occur.

Who is required to file EMPLOYEE PREDESIGNATED TREATING PHYSICIAN NOTIFICATION FORM?

Employees who wish to predesignate a physician for treatment of work-related injuries or illnesses are required to file the EMPLOYEE PREDESIGNATED TREATING PHYSICIAN NOTIFICATION FORM.

How to fill out EMPLOYEE PREDESIGNATED TREATING PHYSICIAN NOTIFICATION FORM?

To fill out the form, the employee should provide their personal information, the designated physician's information, and ensure both parties sign the form to confirm the designation.

What is the purpose of EMPLOYEE PREDESIGNATED TREATING PHYSICIAN NOTIFICATION FORM?

The purpose of the form is to allow employees to select their own physician for treatment of work-related injuries or illnesses, ensuring they receive care from a provider of their choice.

What information must be reported on EMPLOYEE PREDESIGNATED TREATING PHYSICIAN NOTIFICATION FORM?

The information that must be reported includes the employee's name, contact information, the name and address of the designated physician, and signatures from both the employee and the physician.