WORKERS’ COMPENSATION BENEFITS
SELECTION OF PHYSICIAN FOR JOB-RELATED INJURY
All employees have the right to pre-select a physician for treatment in the event of a job-related injury. In order to exercise this right an employee must complete this form. If no physician is designated, the employee will report to the medical facility as directed by the employer for the first 30 days of medical treatment.

DATE: _________________________

TO: RISK Management

FROM: ________________________

SSN#: _______________

SUBJECT: Selection of physician for Job-Related Injury

As required under the California Workers Compensation Act, I have the right to select and be treated by a physician of my choice from the initial date of the injury. This physician has previously directed my medical treatment and retains my medical records.

I understand that in order to exercise my right to choose a physician from the initial date of injury, I must advise the Risk Management Office, in writing, the name and address of my physician prior to the date of injury.

The name, address and telephone number of my physician is:

NAME: _______________________________________________________

MAILING ADDRESS: _______________________________________________________

PHONE NUMBER: __________________________

FAX:___________________________

_______________________________

Employee Signature