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Employees Redesignation of Personal Physician
(California Code of Regulations 9780.1)
In the event that I suffer an onthejob illness/injury, I wish to be treated by the personal physician designated
below.
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How to fill out pdfemployee39s predesignation of personal
To fill out the pdfemployee39's predesignation of personal, follow these steps:
01
Download the pdf form from the designated source or obtain a hardcopy from your employer.
02
Begin by providing your personal information, such as your full name, employee ID, and contact details, in the specified fields.
03
Next, indicate your predesignation of personal physician by entering the name, address, and contact information of your chosen healthcare provider.
04
If applicable, include any additional instructions or preferences regarding your medical treatment and specify the types of treatments you want to predesignate your personal physician for.
05
Sign and date the form to certify its accuracy and completeness.
06
Make a copy of the completed form for your records.
Who needs pdfemployee39's predesignation of personal?
The predesignation of personal form is typically required by employees who want to identify and designate their personal physician for any work-related injuries or illnesses. This form allows individuals to have their preferred healthcare provider treat them if they suffer a workplace injury or require medical attention due to a job-related illness. It is particularly useful for individuals who have an established relationship with a specific physician and wish to receive treatment from them in such situations.
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What is pdfemployee39s predesignation of personal?
Pdfemployee39's predesignation of personal is a form where an employee can designate their preferred healthcare provider in case of a work-related injury.
Who is required to file pdfemployee39's predesignation of personal?
All employees who wish to predesignate their personal healthcare provider in case of a work-related injury are required to file pdfemployee39's predesignation of personal.
How to fill out pdfemployee39's predesignation of personal?
Pdfemployee39's predesignation of personal can be filled out by providing the employee's personal information, the name and contact information of the designated healthcare provider, and the signature of the employee.
What is the purpose of pdfemployee39's predesignation of personal?
The purpose of pdfemployee39's predesignation of personal is to ensure that the employee receives treatment from their preferred healthcare provider in case of a work-related injury.
What information must be reported on pdfemployee39's predesignation of personal?
Pdfemployee39's predesignation of personal must include the employee's personal information, the name and contact information of the designated healthcare provider, and the signature of the employee.
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