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PERSONAL PHYSICIAN REDESIGNATION FOR WORK RELATED INJURIES OR ILLNESS This form must be signed by you AND your personal physician. You must return this original document with All the required signatures

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How to fill out personal physician pre-designation for

01

Obtain a copy of the personal physician pre-designation form from your healthcare provider or insurance company.

02

Fill in your personal information, such as your name, date of birth, and contact information.

03

Provide the name and contact information of your chosen personal physician.

04

If applicable, indicate the effective date of the pre-designation.

05

Sign and date the form.

06

Submit the completed form to your healthcare provider or insurance company as instructed.

Who needs personal physician pre-designation for?

01

Anyone who wants to have control over their healthcare decisions and ensure continuity of care with a specific physician may benefit from personal physician pre-designation.

02

It is particularly important for individuals with chronic or complex medical conditions who have established a strong relationship with a specific healthcare provider.

03

Additionally, those who want to proactively plan for future medical needs or anticipate potential changes in healthcare coverage may find personal physician pre-designation beneficial.

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What is personal physician pre-designation for?

Personal physician pre-designation allows an employee to select their preferred physician or chiropractor to treat them in case of a work-related injury.

Who is required to file personal physician pre-designation for?

Employees are required to file personal physician pre-designation if they want to choose their own doctor for work-related injuries.

How to fill out personal physician pre-designation for?

To fill out personal physician pre-designation, employees must provide the name, contact information, and specialty of the chosen physician or chiropractor.

What is the purpose of personal physician pre-designation for?

The purpose of personal physician pre-designation is to ensure that employees have access to medical care from a doctor they trust in case of a work-related injury.

What information must be reported on personal physician pre-designation for?

The personal physician pre-designation form must include the chosen physician's name, contact information, and specialty.

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