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City and County of San Francisco×Department of Human Resources Connecting People with Purpose www.sfdhr.orgPREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related

How to fill out pre-designation of physician

How to fill out pre-designation of physician form

1. Obtain a pre-designation of physician form from your employer or insurance provider.
2. Read the instructions and guidelines provided on the form carefully.
3. Fill in your personal information accurately, including your name, address, contact number, and social security number.
4. Provide details of your primary care physician, such as name, address, and contact information.
5. If you have any preferred specialists or healthcare providers, list their names and contact information as well.
6. Sign and date the form to acknowledge that the information provided is true and accurate.
7. Submit the completed form to your employer or insurance provider as instructed.
8. Keep a copy of the filled-out form for your records.

Who needs pre-designation of physician form?

1. Pre-designation of physician form is needed by individuals who want to specify their choice of primary care physician or specialists for medical treatments.
2. It is commonly used by employees who have health insurance coverage through their employers or individuals with private health insurance plans.
3. The form allows the insurer to recognize the designated healthcare provider as the primary point of contact and facilitates claim processing and referrals to specialists.

What is Pre-Designation of Physician - Department of Human ... Form?

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Instructions for the Pre-Designation of Physician - Department of Human ... form

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What is pre-designation of physician form?

The pre-designation of physician form is a form that allows an employee to choose their own physician for treatment in case of a work-related injury.

Who is required to file pre-designation of physician form?

Employees who want to choose their own physician for treatment of work-related injuries are required to file the pre-designation of physician form.

How to fill out pre-designation of physician form?

To fill out the pre-designation of physician form, the employee must provide their chosen physician's information, such as name, address, and contact details.

What is the purpose of pre-designation of physician form?

The purpose of the pre-designation of physician form is to give employees the option to seek treatment from their own physician for work-related injuries.

What information must be reported on pre-designation of physician form?

The pre-designation of physician form must include the chosen physician's name, address, and contact details.