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WORKERS’ COMPENSATION

 

 

PRE-INJURY PERSONAL PHYSICIAN SELECTION

From: __________________________________ ____________________________________

(Print Employee's Name) (Department Employed By)

__________________________________ ____________________________________

(Print Employee's Address) (Social Security Number)

__________________________________

I understand that the Workers' Compensation Laws of the State of California indicate that, after thirty (30) days from the date that an on-the-job injury is reported, an employee may be treated by a physician, or a facility, of his/her own choice within a reasonable geographic area. However, if an employee has notified his/her employer in writing prior to the date of injury that he/she has a personal physician, the employee shall have the right to be treated by such physician from the date of injury. As defined by law, "personal physician" means the employee's regular physician and/or surgeon who has previously directed the medical treatment of the employee, and who retains the employee's medical records, including the employee's medical history.

If I become injured on the job, I would like to be treated by my "personal physician" indicated below. I certify that this physician meets the above requirements of a "personal physician" and has previously directed my medical treatment and retains my medical records. The City of Huntington Beach will provide my physician with a copy of this form, which includes the "Duties of the Employee-Selected Physician", as required by law. I understand that, upon receipt of this form, Risk Management will write to my selected physician to verify that he/she is my personal physician (as defined above), and to request that he/she agree, in writing, to comply with the requirements of a physician rendering treatment under the Workers' Compensation Laws of the State of California, should I seek treatment for an on-the-job injury. The validity of this election will be subject to the City's verification that the physician complies with statutory requirements.

Even though I am designating a "personal physician", I understand that my employer may require me to undergo medical examinations by other physicians at their request and expense.

PERSONAL PHYSICIAN: ____________________________________ __________________

(Print Name/Address) (Telephone No.)

____________________________________

____________________________________

I understand that the filing of this form does not relieve me from my obligation to report all injuries immediately to my supervisor and to complete all required reporting forms. I certify that all of the above statements are true and correct to the best of my knowledge.

Date: ___________________ Signed:_______________________________

(Employee)

RETURN ORIGINAL TO RISK MANAGEMENT

Note: All physicians should be aware that it is the practice of the City of Huntington Beach, in the processing and handling of its workers' compensation claims, to pay no more for medical services provided than the amounts set forth in the Official Medical Fee Schedule as adopted by the Administrative Director of the Division of Industrial Accidents.

Employee's Name: ____________________

Social Security No: ____________________

(1) The "primary treating physician" is the physician who is primarily responsible for managing the care of an injured employee and who has examined the employee at least once for the purpose of rendering or prescribing treatment and has monitored the effect of the treatment thereafter. The primary treating physician is the physician selected by the employer or the employee pursuant to Article 2 (commencing with section 4600) of Chapter 2 of Part 2 of Division 4 of the Labor Code, or under the contract or procedures applicable to a Health Care Organization certified under section 4600.5 of the Labor Code.

(2) A "secondary physician" is any physician other than the primary treating physician who examines or provides treatment to the injured employee, but is not primarily responsible for continuing management of the care of the injured employee.

(3) "Claims administrator" is a self-administered insurer providing security for the payment of compensation required by Divisions 4 and 4.5 of the Labor Code, a self-administered self-insured employer, or a third-party administrator for a self-insured employer, insurer, legally uninsured employer, or joint powers authority.

(b) There shall be no more than one primary treating physician at a time. Where the primary treating physician discharges the employee from further treatment and there is a dispute concerning the need for continuing treatment, no other primary treating physician shall be identified unless and until the dispute is resolved. If it is determined that there is no further need continuing treatment, then the physician who discharged the employee shall remain the primary treating physician. If it is determined that there is further need for continuing treatment, a new primary treating physician may be selected.

(c) The primary treating physician, or a physician designated by the primary treating physician, shall make reports to the claims administrator as required in this section. A primary treating physician has fulfilled his or her reporting duties under this section by sending one copy of a required report to the claims administrator. However, a claims administrator may designate any person or entity to be the recipient of the required reports.

(d) The primary treating physician shall render opinions on all medical issues necessary to determine the employee’s eligibility for compensation-in the manner prescribed in subsections (e), (f) and (g) of this section. The primary treating physician may transmit reports to the claims administrator by mail or FAX or by any other means satisfactory to the claims administrator, including electronic transmission.

(e) (1) Within 5 working days following initial examination, a primary treating physician shall submit a written report to the claims administrator on the form entitled "Doctor’s First Report of Occupational Injury or Illness," Form DLSR 5021. Emergency and urgent care physicians shall also submit a Form DLSR 5021 to the claims administrator following each visit. On line 24 of the Doctor’s First Report, or on the reverse side of the form, the physician shall (A) list methods, frequency, and duration of planned treatment(s), (B) specify planned consultations or referrals, surgery or hospitalization and (C) specify the type, frequency and duration of planned physical medicine services (e.g., physical therapy, manipulation, acupuncture).

(2) Each new primary treating physician shall submit a Form DLSR 5021 following the initial examination.

(3) Secondary physicians, physical therapists, and other health care providers to whom the injured employee is referred shall report to the primary treating physician in the manner required by the primary treating physician.

(4) The primary treating physician shall be responsible for obtaining all of the reports of secondary physicians and shall incorporate, or comment upon, the opinions of the other physicians in the primary treating physician’s report and submit all of the reports to the claims administrator.

(f) A primary treating physician shall promptly report to the claims administrator when any one or more of the following occurs:

The employee’s condition undergoes a previously unexpected significant change;

There is any significant change in the treatment plan reported, including, but not limited to, (A) an extension of duration or frequency of treatment, (B) a new need for hospitalization or surgery, (C) a new need for referral to or consultation by another physician, (D) a change in methods of treatment or in required physical medicine services, or (E) a need for rental or purchase of durable medical equipment or orthotic devices;

The employee’s condition permits return to modified or regular work;

The employee’s condition requires him or her to leave work, or requires changes in work restrictions or modifications;

The employee is discharged;

The primary treating physician concludes that the employee’s permanent disability precludes, or is likely to preclude, the employee from engaging in the employee’s usual occupation or the occupation in which the employee was engaged at the time of the injury, as required pursuant to Labor Code Section 4636(b);

The employer reasonably requests additional appropriate information;

When ongoing treatment is provided, a progress report shall be made no later than forty-five days from the last report of any type under this section even if no event described in paragraphs (1) to (7) has occurred.

Reports required under this subdivision shall be submitted on the form entitled "Primary Treating Physician’s Progress Report," Form PR-2, or in the form of a narrative report. If a narrative report is used, it must be entitled "Primary Treating Physician’s Progress Report" in bold-faced type, must indicate clearly the reason the report is being submitted, and must contain the same information using the same subject headings in the same order as Form PR-2.

By mutual agreement between the physician and the claims administrator, the physician may make reports in any manner and form.

(g) When the primary treating physician determines that the employee’s condition is permanent and stationary, the physician shall report any findings concerning the existence and extent of permanent impairment and limitations and any need for continuing or future medical care resulting from the injury. The information may be submitted on the form entitled "Treating Physician’s Permanent and Stationary Report," Form PR-3, or using the instructions on the form entitled "Treating Physician’s Determination of Medical Issues Form," Form IMC 81556, or in such other manner as provides all the information required by Title 8, California Code of Regulations, Section 10606. Qualified Medical Evaluators and Agreed Medical Evaluators may not use Form PR-3 to report medical-legal evaluations.

(h) Any controversies concerning this section shall be resolved pursuant to Labor Code Section 4603 or 4604, whichever is appropriate.

Claims administrators shall reimburse primary treating physicians for their reports submitted pursuant to this section as required by the Official Medical Fee Schedule.

INITIAL AS APPROPRIATE:

________________ I do not agree to accept this employee's designation as his/her pre-industrial injury selected physician.

________________ I am the above-referenced employee's doctor of record, as described on the opposite side of this form. I have read the requirements of an employee-selected physician and I agree to comply with the practices prescribed by the Workers' Compensation Laws of California.

Date: ___________________ Signed:__________________________________

(Doctor)

Print Name:_______________________________

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