Notice Of Predesignation Of Personal Physician {DWC 9783}

DWC FORM 9783 - PREDESIGNATION OF PERSONAL PHYSICIAN. This is a California Division of Workers’ Compensation form used by employees to predesignate their personal medical doctor (M.D.), doctor of osteopathic medicine (D.O.), or qualifying medical group to treat them in the event of a work-related injury or illness. Predesignation is only valid if several requirements are met: the employee has nonoccupational health-care coverage on the date of injury; the chosen physician is the employee’s regular provider who maintains their medical records; and the doctor or medical group agrees in advance to treat work injuries. The employee must provide written notice to the employer before the injury occurs. The form collects employer, physician, employee, and insurance information, and includes an optional signature section for physician confirmation. www.FormsWorkflow.com