Pre-select Physician Form (To be submitted to management)

TO: DATE: SUBJECT:

* * Selection of physician pursuant to California Labor Code §4600.

This notice will serve to inform you that I hereby select the physician listed below to provide medical treatment for any industrial injury which I may sustain and/or to control referral for specialty treatment beyond his/her expertise.

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If you have a different form of notice I request that you provide me with a such form immediately which I will fill in with the name of the same physician I have listed in this memo. I request that a copy of this form and any other form which you may require with regard to pre­selection of my workers' compensation treating physician be placed into my personnel file.

Thank you.



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(SIGNATURE)


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(PRINTED NAME)




*   Enter name of employer.
**  Enter name, address and phone number of preferred physician.