Get Dwc Form 233 - California Department Of Industrial Relations ... - Dir Ca

The DWC Form 233 is a critical document for objecting to a treating physician's recommendation for spinal surgery within California's workers' compensation system. This guide provides step-by-step instructions to help users accurately complete the form online and ensure that all necessary information is included.

Follow the steps to successfully fill out the DWC Form 233 online.

1. Press the ‘Get Form’ button to access the DWC Form 233 online and open it for editing.
2. Begin by entering the employee's last name, first name, any other names or initials, social security number, and date of injury in the designated fields.
3. Fill out the residence address of the employee, including street, city, state, and zip code.
4. Provide the employer's name and the mailing address, followed by details about the insurance carrier, claims administrator, and health care provider.
5. In the section for the employee’s attorney, include their name, mailing address, and telephone number.
6. Input the treating physician’s last name, first name, and other names or initials, along with the mailing address, fax number, and telephone number.
7. List the physician's medical group and independent practice association, if applicable.
8. Clearly state the exact procedure being objected to and provide the name of the facility where this procedure is proposed.
9. If there is an alternative procedure recommended, include the name of the facility where this proposed procedure will occur.
10. Indicate the date the treating physician’s recommendation was first received and the entity that received it.
11. Specify the type of entity that received the recommendation (employer, insurance carrier, or administrator).
12. Enter the name and contact details of the person signing the objection, including their mailing address, telephone number, company, and email.
13. Clearly articulate the reasons for the objection in the space provided, making sure to be specific to the employee.
14. Complete the declaration stating the date the recommendation was received and the date on which the objection was served, including the name of the person served.
15. Sign the form as required, ensuring it is dated and includes the means of service.
16. Once all fields are filled, save your changes and opt to download, print, or share the completed form as needed.

Complete your DWC Form 233 online today to ensure that your objection is processed efficiently.