Free NOTICE OF PERSONAL CHIROPRACTOR OR PERSONAL ACUPUNCTURIST - California


File Size: 38.1 kB
Pages: 1
Date: March 14, 2006
File Format: PDF
State: California
Category: Workers Compensation
Author: Administrator
Word Count: 180 Words, 1,678 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dir.ca.gov/dwc/FORMS/DWCForm_9783_1.pdf

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NOTICE OF PERSONAL CHIROPRACTOR OR PERSONAL ACUPUNCTURIST If your employer or your employer's insurer does not have a Medical Provider Network, you may be able to change your treating physician to your personal chiropractor or acupuncturist following a work-related injury or illness. In order to be eligible to make this change, you must give your employer the name and business address of a personal chiropractor or acupuncturist in writing prior to the injury or illness. Your claims administrator generally has the right to select your treating physician within the first 30 days after your employer knows of your injury or illness. After your claims administrator has initiated your treatment with another doctor during this period, you may then, upon request, have your treatment transferred to your personal chiropractor or acupuncturist. You may use this form to notify your employer of your personal chiropractor or acupuncturist.

Your Chiropractor or Acupuncturist's Information: ______________________________________________________________________________ (name of chiropractor or acupuncturist) ______________________________________________________________________________ (street address, city, state, zip code) ______________________________________________________________________________ (telephone number)

Employee Name (please print): ______________________________________________________________________________ Employee's address: ______________________________________________________________________________ Employee's Signature_______________________________________________Date:_______________

DWC FORM 9783.1 (March 14, 2006)