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PERSONAL PHYSICIAN PRE-DESIGNATION FOR WORK RELATED INJURIES OR ILLNESS
This form must be signed by you AND your personal physician. You must return this original document
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How to fill out personal physician pre-designation for
How to fill out personal physician pre-designation form:
01
Obtain the form: The personal physician pre-designation form can usually be obtained from your employer, insurance company, or healthcare provider. You may also find it online on their respective websites.
02
Provide personal information: Fill out your personal information accurately, including your full name, address, date of birth, and contact details. This information helps to properly identify you and ensure that the form is associated with the correct individual.
03
Enter your current primary care physician: Identify your current primary care physician by providing their full name, address, and contact information. This is the physician you typically visit for general health check-ups and non-emergency medical care.
04
List any specialists you visit regularly: If you regularly see any specialists, such as a cardiologist, dermatologist, or psychiatrist, include their information as well. Provide their full names, addresses, and contact details.
05
Choose an alternative physician: In case your primary care physician or any of your regular specialists are not available, you have the option to designate an alternative physician. This could be another healthcare professional who is familiar with your medical history and can provide care if your primary physicians are unavailable.
06
Review and sign the form: Carefully review all the information you have provided in the form. Double-check the accuracy of names, addresses, and contact details. Once you are satisfied, sign and date the form to indicate your agreement and understanding.
Who needs personal physician pre-designation:
01
Employees with employer-sponsored health plans: Many employers offer health insurance to their employees, and often require employees to designate a personal physician. This helps the insurance company in providing coordinated care and managing healthcare costs.
02
Individuals with managed care plans: Those enrolled in managed care plans, such as health maintenance organizations (HMOs) or preferred provider organizations (PPOs), may be required to choose a personal physician for their primary healthcare needs.
03
People with chronic medical conditions: Individuals with chronic conditions, such as diabetes, heart disease, or cancer, may benefit from designating a personal physician who can coordinate their care and monitor their specific health needs.
By filling out a personal physician pre-designation form, individuals can ensure that they receive consistent and coordinated healthcare from a trusted healthcare professional who understands their medical history and specific needs.
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What is personal physician pre-designation for?
Personal physician pre-designation is for selecting a specific doctor to treat a work-related injury or illness.
Who is required to file personal physician pre-designation for?
Employees who want to choose their own doctor for work-related injuries or illnesses are required to file personal physician pre-designation.
How to fill out personal physician pre-designation for?
To fill out personal physician pre-designation, employees need to provide their chosen doctor's information and submit the form to their employer.
What is the purpose of personal physician pre-designation for?
The purpose of personal physician pre-designation is to ensure employees have access to the medical care they prefer in the event of a work-related injury or illness.
What information must be reported on personal physician pre-designation for?
Employees must report their chosen doctor's name, address, phone number, and specialty on personal physician pre-designation.
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