Personal Physician Designation Form

Give this form to every employee prior to the end of the first payroll period following initial employment. It may be given as part of the Workers' Compensation Information Pamphlet, which must be provided at that time. The form must also be given to any employee who wants to pre-designate a personal physician (M.D., D.O. or medical group) as treating doctor for a work-related injury, upon request, at any time during employment.
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