Get the free Pre-Designation Physician Form - Los Angeles Unified School District

Los Angeles Unified School District Workers Compensation Program Redesignation of Physician Form In the event of a work related injury or illness, I request to be treated by my personal physician.

How to fill out pre-designation physician form

How to fill out the pre-designation physician form:

1. Begin by downloading or obtaining the pre-designation physician form from your employer or insurance provider.
2. Fill in your personal information, such as your name, address, contact number, and employee or member identification number.
3. Provide details about your preferred physician by including their name, address, and contact information.
4. Specify the effective date for the pre-designation physician, which is typically the date when you want the designation to start.
5. Make sure to read and understand any additional instructions or requirements specified on the form, such as limitations or conditions for pre-designation.
6. Sign and date the form to indicate your agreement and understanding.
7. Submit the completed form to your employer or insurance provider as per their instructions.

Who needs a pre-designation physician form:

1. Employees or members who have an employee health insurance plan or a group health insurance plan may need to fill out a pre-designation physician form.
2. This form is particularly relevant for individuals who have a preferred physician they want to designate for future medical treatment or care.
3. It is important to check with your employer or insurance provider to determine if they require the use of a pre-designation physician form and if it is applicable to your specific plan.

For pdfFiller’s FAQs

What is pre-designation physician form?

The pre-designation physician form is a form that allows an employee to choose their own physician or healthcare provider to treat a work-related injury or illness.

Who is required to file pre-designation physician form?

Employees who want to choose their own physician or healthcare provider to treat a work-related injury or illness are required to file the pre-designation physician form.

How to fill out pre-designation physician form?

To fill out the pre-designation physician form, the employee must provide their chosen physician or healthcare provider's contact information and sign the form.

What is the purpose of pre-designation physician form?

The purpose of the pre-designation physician form is to allow employees to receive treatment from a physician or healthcare provider of their choosing for a work-related injury or illness.

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

The pre-designation physician form must include the chosen physician or healthcare provider's contact information and the employee's signature.

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