Predesignation of Personal Physician Form

Predesignation of Personal Physician Form
Predesignation of personal physician
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.), Doctor of Osteopathic
Medicine (D.O.) or medical group if:
• On the date of your work injury you have health care
coverage for injuries or illnesses that are not work related
• The doctor is your regular physician, who shall be either a
physician who has limited his or her practice of medicine to
general practice or who is a board-certified or board-eligible
internist, pediatrician, obstetrician-gynecologist, or family
practitioner, and has previously directed your medical
treatment, and retains your medical records
• Your “personal physician” may be a medical group if it is a
single corporation or partnership composed of licensed doctors
of medicine or osteopathy, which operates an integrated
multispecialty medical group providing comprehensive medical
services predominantly for nonoccupational illnesses and injuries
• Prior to the injury your doctor agrees 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 doctor’s name and business address
You may use this form to notify your employer if you wish to
have your personal medical doctor or a doctor of osteopathic
medicine treat you for a work-related injury or illness and the
above requirements are met.
Notice of predesignation of personal physician
Employee: Complete this section.
If I have a work-related injury or illness, I choose to be treated by:
Name of Physician or Medical Group
Physician or Medical Group address
State
Employee name (please print)
Employee address
State
Date
Physician: I agree to this predesignation.
Date
Keep Copy and Return Original to: Risk Management, 215 Panama St., Juniper, Bldg D,
Stanford CA 94305-6207 or ID Mail: 6207
Designación previa de médico particular
En caso de que usted sufra una lesión o enfermedad
relacionada con su empleo, usted puede recibir tratamiento
médico por esa lesión o enfermedad de su médico particular
(M.D.), médico osteópata (D.O.) o grupo médico si:
• Usted tiene un plan de salud grupal
• El médico es su médico familiar o de cabecera, que será
un médico que ha limitado su práctica médica a medicina
general o que es un internista certificado o elegible para
certificación, pediatra, gineco-obstreta, o médico de
medicina familiar y que previamente ha estado a cargo
de su tratamiento médico y tiene su expediente médico
• Su “médico particular” puede ser un grupo médico si
es una corporación o sociedad o asociación compuesta
de doctores certificados en medicina u osteopatía, que
opera un integrado grupo médico multidisciplinario que
predominantemente proporciona amplios servicios médicos
para lesiones y enfermedades no relacionadas con el trabajo
• antes de la lesión su médico está de acuerdo a proporcionarle
tratamiento médico para su lesión o enfermedad de trabajo
• antes de la lesión usted le proporcionó a su empleador por
escrito lo siguiente: (1) notificación de que quiere que su
médico particular le brinde tratamiento para una lesión o
enfermedad de trabajo y (2) el nombre y dirección comercial
de su médico particular
Puede utilizar este formulario para notificarle a su empleador
que desea que su médico particular o médico osteópata lo
atienda para una lesión o enfermedad de trabajo y que los
requisitos mencionados arriba han sido cumplidos.
Noticia de designación previa de médico particular
Nombre del empleador
Estado
Nombre del empleado
(con letra de molde)
Fecha
Estado
de salud para las lesiones y enfermedades no relacionadas con el trabajo:
Firma del empleado
Médico: Estoy de acuerdo con esta Designación Previa.
Fecha
Keep Copy and Return Original to: Risk Management, 215 Panama St., Juniper, Bldg D,
Stanford CA 94305-6207 or ID Mail: 6207
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