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Workers Compensation Personal Physician Designation Form
WORKERS COMPENSATION PERSONAL PHYSICIAN DESIGNATION FORM
TO: [First Name of employee] [Last Name of employee]
[Title of employee]
FROM: [First Name of employer] [Last Name of employer]
[Title of employer]
DATE: [Date]
RE: Workers Compensation Personal Physician Designation Form
If you are injured or become ill during the conduct of work-related activities, [Name of Company] will select the treating physician for the first [Amount of days] days after the injury/illness has been reported UNLESS you notify the Company prior to sustaining the injury/illness that you have a personal physician by whom you wish to be treated.
You must complete the form below and return it to my attention PRIOR to sustaining a work-incurred injury/illness.
A copy of the Personnel Policy is attached for your information and is also posted on the bulletin boards.
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WORKERS COMPENSATION PERSONAL PHYSICIAN DESIGNATION FORM
In case of a work-incurred injury/illness, I designate the following physician to direct any medical treatment required as a result of a workers compensation injury/illness sustained while an employee of [Your Company]:
NAME OF PHYSICIAN:
ADDRESS:
PHONE NUMBER:
I understand that this designated physician will be required to submit a report to the Company within five (5) working days from the date of the initial consultation and may also be required to submit periodic reports thereafter as it relates to any work-incurred injury or illness.
I further understand that if I go to a medical doctor or a medical facility other than the one specifically designated on this form or one designated by [Name of Company], then the Company has the right to refuse to pay for such treatment.
Type or Print Name
Employee Signature Date