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 9783.1 - DWC Form 9783.1 Notice of Personal Chiropractor or Personal Acupuncturist

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
NOTICE OF PERSONAL CHIROPRACTOR OR PERSONAL
						ACUPUNCTURIST
If your employer or your employer's insurer does not have
						a Medical Provider Network, you may be able to change your treating physician
						to your personal chiropractor or acupuncturist following a work-related injury
						or illness. In order to be eligible to make this change, you must give your
						employer the name and business address of a personal chiropractor or
						acupuncturist in writing prior to the injury or illness. Your claims
						administrator generally has the right to select your treating physician within
						the first 30 days after your employer knows of your injury or illness. After
						your claims administrator has initiated your treatment with another doctor
						during this period, you may then, upon request, have your treatment transferred
						to your personal chiropractor or acupuncturist.
NOTE: If your date of injury is January 1, 2004 or later,
						a chiropractor cannot be your treating physician after you have received 24
						chiropractic visits unless your employer has authorized additional visits in
						writing. The term "chiropractic visit" means any chiropractic office visit,
						regardless of whether the services performed involve chiropractic manipulation
						or are limited to evaluation and management. Once you have received 24
						chiropractic visits, if you still require medical treatment, you will have to
						select a new physician who is not a chiropractor. This prohibition shall not
						apply to visits for postsurgical physical medicine visits prescribed by the
						surgeon, or physician designated by the surgeon, under the postsurgical
						component of the Division of Workers' Compensation's Medical Treatment
						Utilization Schedule.
You may use this form to notify your employer of your
						personal chiropractor or acupuncturist.
Your Chiropractor or Acupuncturist's
						Information:
___________________________
(name of chiropractor or acupuncturist)
___________________________
(street address, city, state, zip code)
___________________________
(telephone number)
___________________________
Employee Name (please print):
___________________________
Employee's Address:
___________________________
Employee's
___________________________
Signature __________________________ Date:
						________________________
Title 8, California Code of Regulations, section
						9783.1.
(Optional DWC Form 9783.1 Effective date July 1,
						2014)
1. New
						section filed 3-14-2006; operative 3-14-2006 pursuant to Government Code
						section
						11343.4
						(Register 2006, No. 11).
2. 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: Sections
						  4600 and
						  4601, Labor
						  Code.