To (Name of Employer):

_________________________________________________________________________________________________________________________
In the event that I sustain a job-related illness or injury, I designate my personal physician to provide medical care immediately after the injury, and for the purpose of all related care, as appropriate, for the duration of my treatment for that illness or injury. My physician has agreed to be pre-designated. By making this request, I am not waiving my right to immediate, appropriate and adequate emergency treatment in instances where my personal physician is unavailable, nor am I waiving my right to be referred to specialists or other providers as necessary.

Personal Physician:

_________________________________________________________________________________________________________________________
(Physician’s name, office, clinic or hospital)

Address:

_______________________________________________________________________________

_______________________________________________________________________________

Telephone: ______________________________________________________

Employee’s signature:_______________________________________________________________

Employee’s name (print);____________________________________________________________

Date: _______________________________________

Instructions: In accordance with the new worker’s compensation reform law enacted April 19, 2004, as it amends Labor Code Section 4600, if your employer provides group health coverage, you are allowed to pre-designate your primary care physician from your employer-provided group health coverage plan as your personal physician for your worker’s compensation medical treatment. If you pre-designate your personal physician, you will be allowed to be treated by this doctor immediately after you are injured. If you fail to pre-designate your personal physician, your employer may select a physician for you from the date of injury.