California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5 - Predesignation of Personal Physician; Request for Change of Physician; Reporting Duties of the Primary Treating Physician; Petition for Change of Primary Treating Physician › Section 9783 - DWC Form 9783 Predesignation of Personal Physician

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
PREDESIGNATION 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.), doctor of osteopathic medicine (D.O.) or medical group
						if:
* on the date of your work injury you have health care
						coverage for injuries or illnesses that are not work related;
* the doctor is your regular physician, who shall be
						either a physician who has limited his or her practice of medicine to general
						practice or who is a board-certified or board-eligible internist, pediatrician,
						obstetrician-gynecologist, or family practitioner, and has previously directed
						your medical treatment, and retains your medical records;
* your "personal physician" may be a medical group if it
						is a single corporation or partnership composed of licensed doctors of medicine
						or osteopathy, which operates an integrated multispecialty medical group
						providing comprehensive medical services predominantly for nonoccupational
						illnesses and injuries;
* prior to the injury your doctor agrees to treat you for
						work injuries or illnesses;
* prior to the injury you provided your employer the
						following in writing:
(1) notice that
					 you want your personal doctor to treat you for a work-related injury or
					 illness, and
(2) your personal
					 doctor's name and business address.
You may use this form to notify your employer if you wish
						to have your personal medical doctor or a doctor of osteopathic medicine treat
						you for a work-related injury or illness and the above requirements are
						met.
NOTICE OF PREDESIGNATION OF PERSONAL
						PHYSICIAN
Employee: Complete this section.
To: ______________________________(name of employer) If I
						have a work-related injury or illness, I choose to be treated by:
___________________________
(name of doctor)(M.D., D.O., or medical group)
______________________________ (street address, city,
						state, ZIP)
_________________________ (telephone number)
Employee Name (please print):
___________________________
Employee's Address:
___________________________
Name of Insurance Company, Plan, or Fund providing health
						coverage for nonoccupational injuries or illnesses:
___________________________
Employee's
___________________________
Signature
__________________________________________________
Date:
Physician: I agree to this
						Predesignation:
___________________________
Signature:
__________________________________________________
Date:
(Physician or Designated Employee of the Physician or
						Medical Group)
The physician is not required to sign this form, however,
						if the physician or designated employee of the physician or medical group does
						not sign, other documentation of the physician's agreement to be predesignated
						will be required pursuant to Title 8, California Code of Regulations, section
						9780.1(a)(3).
Title 8, California Code of Regulations, section
						9783.
(Optional DWC Form 9783-July 1, 2014)
1.
						Amendment filed 11-11-78; effective thirtieth day thereafter (Register 78, No.
						45).
2. Repealer and new section heading, section and NOTE filed
						3-14-2006; operative 3-14-2006 pursuant to Government Code section
						11343.4
						(Register 2006, No. 11).
3. Change without regulatory effect
						amending section filed 2-21-2007 pursuant to section
						100, title 1, California Code of
						Regulations (Register 2007, No. 8).
4. Amendment filed 2-12-2014;
						operative 7-1-2014 pursuant to Government Code section
						11343.4
						(Register 2014, No. 7).
Note: Authority cited: Sections
						  133,
						  4603.5 and
						  5307.3, Labor
						  Code. Reference: Section
						  4600, Labor
						  Code