Petition For Change Of Primary Treating Physician {DWC 280}

DWC Form 280 - PETITION FOR CHANGE OF PRIMARY TREATING PHYSICIAN (LABOR CODE § 4603 & TITLE 8, CALIFORNIA CODE OF REGULATIONS, § 9786). This form is issued by the California Division of Workers’ Compensation for employees or their representatives to request a change of primary treating physician. Part A collects case information, the names and addresses of the employee, employer, claims administrator, current treating physician, and a panel of five alternative physicians available to assume care if the petition is granted. The petitioner must state good cause for the change and attach supporting medical evidence, then complete a verification and proof of service. Part B provides the official response form for the employee, attorney, or physician to contest the petition, with space for supporting evidence and a required proof of service. www.FormsWorkflow.com