ALL California Employees Should Predesignate A Doctor Before A Work Injury
If you predesignate, you may see your personal physician or medical group right after you are injured.
How to predesignate a doctorTo predesignate your personal physician (if you are eligible to do so), you must notify your employer
in writing. You may prepare your own written statement, use optional DWC Form 9783 provided by
the Division of Workers* Compensation, or use a form provided by your employer.
To download DWC Form 9783, go to www.dir.ca.gov/dwc/forms.html.
Note: If your employer or the insurer has a contract with a health care organization (HCO), you must
use a different form, discussed on the next page.
Make sure to include the following information:
1. Name of your employer
2. A statement that if you are hurt on the job, you designate your personal physician to provide
medical care. Give the name, address, and phone number of your physician.
3. Your name
4. Your signature
You can predesignate a doctor of medicine (MD) or doctor of osteopathy (DO) who treated you in the
past and has your medical records. The doctor must be a general practitioner, internist, pediatrician,
obstetrician-gynecologist, or family practitioner who is your primary care physician.
You cannot predesignate your personal chiropractor or acupuncturist, but if you give your employer
the name of your personal chiropractor or acupuncturist in writing before you are injured, you may
switch to this chiropractor or acupuncturist upon request, after you first see a doctor chosen by a
claims administrator (a person who handles workers* compensation claims for your employer).
You may also predesignate a medical group if it meets the following criteria:
* Is composed of licensed doctors of medicine (MD) or doctors of osteopathy (DO)
* Offers and coordinates both primary care and care in other medical specialties
* Mostly treats medical conditions that are unrelated to work
You cannot predesignate unless the physician or medical group you predesignate agrees in advance
to treat you for job injuries and illnesses. You can document the agreement by having the physician,
an employee of the physician, or an employee of the medical group sign the predesignation form, or
by some other form of documentation. Include the documentation when you give your employer the
predesignation form or statement.
NIKKI MEHRPOO JACOBSON
Attorney at Law
Workers' Compensation | Immigration
Call or Text (310) 277-2266
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