 MEMBER
TIPS
 Designated
Physician
Instructions to
complete Form 9783 Predesignation of Personal Physician & Form 9783.1 Notice
of Personal Chiropractor or Personal Acupuncturist:
If you haven’t already done so, PLEASE take the time to fill out and
turn in a Predesignation of Personal Physician form. There are 2 forms to
choose from; one form if you are designating a chiropractor or acupuncturist
and the other form for all medical doctors or doctor of osteopathic medicine
(D.O.). Once you have filled out a form and turned it in to your department
AND we have your physician’s agreement to treat you for a
work-related injury, then you may see your OWN physician in case of a
work-related injury or illness. REMEMBER, this is to be completed
prior to any notice of a work-related injury or illness. This means you are
under the medical care of your own personal physician. If you select a
chiropractor or acupuncturist, you will not be allowed to treat with him/her
until after the first 30 days following the injury; provided you have not
been discharged from care.
The form is available on-line or in hard copy 3-part form (triplicate).
Regardless of which is used, the originally signed copy goes to Risk
Management Division, one copy stays in your department file and one copy
stays with you. Please make sure your immediate supervisor is also aware
that you have this form on file. California Labor Code Section 4600 enables
employees to designate their personal physician prior to an industrial
injury or illness. Personal physician means “the employee’s regular
physician, who has previously directed the medical treatment of the
employee, who retains the employee’s medical records including the medical
history and agrees to treat the employee for a work-related injury.”
Following are
the links for the website and forms:
PREDESIGNATION OF
PERSONAL PHYSICIAN SELECTION
http://www.dir.ca.gov/dwc/FORMS/DWCForm_9783.pdf
PREDESIGNATION OF
PERSONAL CHIROPRACTOR/ACUPUNCTURIST SELECTION
http://www.dir.ca.gov/dwc/FORMS/DWCForm_9783_1.pdf
Courtesy of:
Patrick R.
Fuleihan
Workers' Compensation Administrator
City of Santa Monica
Phone: 310.458.8369 |
site
MAP
