Californians Injured At Work

Labor Code Section 4600 and Title 8 of the California Code of Regulations, Section 9780.1(a)(3), permit an employee, the right to pre-designate his or her medical treater in the case of a work-incurred injury or illness.

It is imperative that you pre-designate your medical treater in the case of a work-incurred injury or illness or you may be forced to be treated by an employer chosen physician from their Medical Provider Network which leaves your medical care and treatment in the hands of your employer and their insurer.

In the event that you sustain an injury or illness related to your employment, you may be treated for such injury or illness by your personal medical doctor (M.D.) or doctor of osteopathic medicine (D.O.) if:

your employer offers group health coverage;
the doctor is your regular physician, who shall be either a physician who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist, or family practictioner, and has previously directed your medical treatment and retains your medical records;
prior to the injury, your doctor agrees to treat you for work injuries or illnesses;
prior to the injury, you provided your employer the following in writing: (1) notice that you want your personal doctor to treat you for a work-incurred injury or illness, and (2) your personal doctor's name and business address.

You may use either of the form links below to print out the form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met.

"Request To Pre-Designate Physician In Case Of Work-Incurred Injury Or Illness" form in Microsoft Word Format.

"Request To Pre-Designate Physician In Case Of Work-Incurred Injury Or Illness" form in Adobe Portable Document (PDF) Format.

Print Three (3) copies of the form, fill out, sign & distribute;

For your personal records;

For your employer;

For your union representatives, should you belong to one.

Title 8, California Code of Regulations
Section 9780.1. Employee's Predesignation of Personal Physician

(a) An employee may be treated for an industrial injury in accordance with section 4600 of the Labor Code by a personal physician that the employee predesignates prior to the industrial injury if the following three conditions are met:

Notice of the predesignation of a personal physician is in writing, and is provided to the employer prior to the industrial injury for which treatment by the personal physician is sought. The notice shall include the personal physician's name and business address.
The employer provides: (i) nonoccupational group health coverage in a health care service plan, licensed pursuant to Chapter 2.2 (commencing with section 1340) of Division 2 of the Health and Safety Code, or (ii) nonoccupational health coverage in a group health plan or a group health insurance policy as described in section 4616.7 of the Labor Code. The employer's provision of health coverage as defined herein is sufficient to meet this requirement, regardless of whether the employee accepts or participates in this health coverage.
The employee's personal physician agrees to be predesignated prior to the injury. The personal physician may sign the optional predesignation form (DWC Form 9783) in section 9783 as documentation of such agreement. The physician may authorize a designated employee of the physician to sign the optional predesignation form on his or her behalf. If the personal physician or the designated employee of the physician does not sign a predesignation form, there must be other documentation that the physician agrees to be predesignated prior to the injury in order to satisfy this requirement.

(b) If an employee has predesignated a personal physician prior to the effective date of these regulations, such predesignation shall be considered valid if the conditions in subdivision (a) have been met.

(c) Where an employer or an employer's insurer has a Medical Provider Network pursuant to section 4616 of the Labor Code, an employee's predesignation which has been made in accordance with this section shall be valid and the employee shall not be subject to the Medical Provider Network.

(d) Where an employee has made a valid predesignation pursuant to this section, and where the employer or employer's insurer has a Medical Provider Network, any referral to another physician for other treatment need not be within the Medical Provider Network.

(e) An employer who qualifies under (a)(2) of this section shall notify its employees of all of the requirements of this section and provide its employees with an optional form for predesignating a personal physician, in accordance with section 9880. The employer may use the predesignation form (DWC Form 9783) in section 9783 for this purpose.

(f) Unless the employee agrees, neither the employer nor the claims administrator shall contact the predesignated personal physician to confirm predesignation status or contact the personal physician regarding the employee's medical information or medical history prior to the personal physician's commencement of treatment for an industrial injury.

(g) Where the employer has been notified of an employee's predesignation of a personal physician in accordance with this section and where the employer becomes liable for an employee's medical treatment, the claims administrator shall:

authorize the predesignated physician to provide all medical treatment reasonably required to cure or relieve the injured employee from the effects of his or her injury;
furnish the name and address of the person to whom billing for treatment should be sent;
where there has been treatment of an injury prior to commencement of treatment by the predesignated physician, arrange for the delivery to the predesignated physician of all medical information relating to the claim, all X-rays, the results of all laboratory studies done in relation to the injured employee's treatment; and
provide the physician with:
1. the fax number, if available, to be used to request authorization of treatment plans;
2. the complete requirements of section 9785; and
3. the forms set forth in sections 9785.2 and 9785.4. In lieu of providing the materials required in (2) and (3) immediately above, the claims administrator may refer the physician to the Division of Workers' Compensation's website where the applicable information and forms can be found at http://www.dir.ca.gov/DWC/dwc_home_page.htm.

(h) Notwithstanding subdivision (g), the employer shall provide first aid and appropriate emergency health care services reasonably required by the nature of the injury or illness. Thereafter, if further medical treatment is reasonably required to cure or relieve the injured employee from the effects of his or her injury, the claims administrator shall authorize treatment with the employee's predesignated personal physician in accordance with subdivision (g).

(i) If documentation of a physician's agreement to be predesignated has not been provided to the employer as of the time of injury, treatment shall be provided in accordance with Labor Code section 4600, or Labor Code section 4616, if the employer or insurer has established a Medical Provider Network, as though no predesignation had occurred. Upon provision of the documented agreement that was made prior to injury that meets the conditions of Labor Code section 4600(d), the employer or claims administrator shall authorize treatment with the employee's predesignated physician as set forth in subdivision (g).