Get the free Predesignation Form - Coast Community College District - cccd

Form101006 Page 1 of 3 Coast Community College Coast Community College District Workers' Compensation 1370 Adams Ave ? Costa Mesa CA 92626 ? 714-438-4864 ? Fax 714-438-4773 ? To: Benefits Eligible

How to fill out predesignation form - coast

How to Fill Out Predesignation Form - Coast:

1. Obtain the predesignation form: Start by obtaining the predesignation form from your employer or the workers' compensation insurance company. You can usually find this form on their website or request a physical copy.
2. Fill in your personal information: Provide your full name, address, phone number, and email address in the designated spaces on the form. Make sure to write legibly and use accurate information.
3. Enter your employer's details: Fill in the necessary information about your employer, such as their company name, address, and contact information. This will help in identifying your workplace and connecting the form to your employment.
4. Specify the designated physician: In the form, indicate the name and contact details of the healthcare professional you wish to designate for treating any workplace-related injuries. This could be your primary care physician, a specialist, or a medical group of your choice.
5. Sign and date the form: Read the predesignation form carefully, ensuring that all the information provided is accurate. Once verified, sign and date the form at the designated area to confirm your consent and acknowledgement.

Who Needs Predesignation Form - Coast:

1. Current employees: If you are currently employed and wish to predesignate a specific healthcare provider to treat any potential workers' compensation injuries, you need to fill out a predesignation form. This ensures that your chosen healthcare professional is aware of your preference before any accidents or injuries occur.
2. New employees: When newly hired, it is advisable to complete a predesignation form if you already have a preferred physician or medical group. This ensures continuity of care in case of any future workplace injuries.
3. Individuals with existing predesignation: Even if you have already filled out a predesignation form in the past, it is recommended to review and update the form periodically. Changes in personal details or healthcare providers may require you to submit an updated predesignation form to ensure accurate information for potential workers' compensation claims.

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What is predesignation form - coast?

Predesignation form - coast is a form used by employees to designate their personal physician or medical group before they sustain a work-related injury or illness.

Who is required to file predesignation form - coast?

All employees in California are required to file predesignation form - coast if they want to designate their personal physician or medical group for work-related injuries.

How to fill out predesignation form - coast?

The predesignation form - coast can be filled out by providing the required information such as employee's personal physician or medical group details, and submitting it to the employer.

What is the purpose of predesignation form - coast?

The purpose of predesignation form - coast is to allow employees to choose their personal physician or medical group to provide treatment for work-related injuries or illnesses.

What information must be reported on predesignation form - coast?

The predesignation form - coast must include details of the employee's personal physician or medical group such as name, address, phone number, and any other required information by the employer.