Get Personal Physician Designation Form Dwc Form 9783

This guide provides clear and concise instructions for completing the Personal Physician Designation Form DWC FORM 9783 online. It is important to accurately complete this form to ensure your personal physician can provide treatment for work-related injuries or illnesses.

Follow the steps to fill out the form correctly online.

1. Click the ‘Get Form’ button to access the Personal Physician Designation Form DWC FORM 9783 and open it for editing.
2. In the 'To' section, enter the name of your employer. This identifies where your predesignation is directed.
3. In the section titled 'If I have a work-related injury or illness, I choose to be treated by:', fill in the name of your selected physician, ensuring to include either 'M.D.' or 'D.O.' if applicable.
4. Provide the complete address of your physician, including the street address, city, state, and zip code in the respective fields.
5. Enter the telephone number of your physician in the designated field, formatted appropriately.
6. Print your name in the 'Employee Name' section to confirm your identity.
7. Fill out your own address details in the corresponding fields, including street address, city, state, and zip code.
8. Sign and date the form in the 'Employee Signature' section to validate your request.
9. If applicable, the physician or a designated employee must sign and date the section indicating their agreement to the predesignation.
10. Review all entered information for accuracy before finalizing. Save changes, download a copy for your records, and print or share the completed form as needed.

Complete your documents online today to ensure your personal physician is designated for treatment.