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REDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment, you may be treated for such injury or illness by your personal medical doctor (M.D.×,
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How to fill out provider predesignation form dwcform9783pdf
How to fill out provider predesignation form dwcform9783pdf
01
To fill out the provider predesignation form dwcform9783pdf, follow these steps:
02
Access the form: Go to the official website of the DWC (Division of Workers' Compensation) and locate the provider predesignation form dwcform9783pdf.
03
Download the form: Save the form on your computer or device.
04
Open the form: Use a PDF reader or editor to open the downloaded form.
05
Fill in your personal information: Enter your full name, date of birth, and contact details as requested.
06
Fill in the employer information: Provide details about your current or potential employer, including the company name and address.
07
Enter the provider details: Provide the name and contact information of the healthcare provider you are designating.
08
Specify the type of provider: Indicate whether the designated provider is a personal physician, medical group, or a healthcare provider designated by your employer.
09
Sign and date the form: If required, physically sign the form and provide the date of signing.
10
Submit the form: Follow the instructions provided on the DWC website or on the form itself to submit the completed form.
11
Retain a copy: Make sure to keep a copy of the filled-out form for your records.
Who needs provider predesignation form dwcform9783pdf?
01
The provider predesignation form dwcform9783pdf is needed by employees who wish to predesignate their personal physician or medical group for workers' compensation purposes.
02
This form allows employees to choose their own healthcare provider in the event of a work-related injury or illness, ensuring they receive medical treatment from a trusted medical professional.
03
It is especially relevant for employees who have a pre-existing relationship with a specific physician or medical group and want to ensure they have access to that provider in case of any work-related medical needs.
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What is provider predesignation form dwcform9783pdf?
Provider predesignation form dwcform9783pdf is a form used by injured workers in California to designate a personal physician or medical group before a work-related injury occurs.
Who is required to file provider predesignation form dwcform9783pdf?
Injured workers in California are required to file provider predesignation form dwcform9783pdf to designate a personal physician or medical group.
How to fill out provider predesignation form dwcform9783pdf?
To fill out provider predesignation form dwcform9783pdf, the injured worker must provide their personal information, the name of the physician or medical group they are designating, and sign and date the form.
What is the purpose of provider predesignation form dwcform9783pdf?
The purpose of provider predesignation form dwcform9783pdf is to allow injured workers in California to choose their personal physician or medical group before a work-related injury occurs.
What information must be reported on provider predesignation form dwcform9783pdf?
Provider predesignation form dwcform9783pdf requires the injured worker's personal information, the name of the designated physician or medical group, and the injured worker's signature and date.
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