INSTRUCTIONS:
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. or doctor of osteopathy (D.O.) if:
your
employer offers group health coverage;
the doctor
has treated you in the past and has your medical records;
prior
to injury your doctor has signed below agreeing 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 doctorís name and business address.
This form may be used to notify your employer if you wish to have
your personal medical doctor or a doctor of osteopathy treat you for a
work-related injury or illness and the above requirements are met.
Print three copies, sign and distribute: (1) Employer (2) Local 70 (3) Employee Copy
NOTICE OF PREDESIGNATION OF PERSONAL
PHYSICIAN
EMPLOYEE: COMPLETE THIS SECTION
Employer
Name
If I have a work-related injury or illness, I choose
to be treated by:
Name of Physician - M.D./D.O.
Street Address of Physician
City/State/Zip Telephone No.
Employee
Last
First
M.I.
Employee
Signature: _______________________________________________Date: _________
PHYSICIAN: COMPLETE
THIS SECTION
I AGREE TO THIS PREDESIGNATION
Physician
Signature: ________________________________________________Date: ________
Physician
or Designated Employee of Physician
The physician is not required to sign
this form, however, if the physician or designated employee of the physician
does not sign, other documentation of the physicianís agreement to be predesignated will be required pursuant to Section
9780.1(a)(3).
Title 8.
(Draft Regulations ñ DWC Form
9782 dated May 2005)
opeiu29/afl-cio