Get Kaiser On-the Job Occupational Health Treatment Referral Form - Documents Dgs Ca

Filling out the KAISER ON-THE JOB Occupational Health Treatment Referral Form correctly is essential for ensuring appropriate medical treatment for work-related injuries or illnesses. This guide provides a step-by-step overview to help you easily complete the form online.

Follow the steps to fill out the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Provide the date in the designated field at the top of the form.
3. Enter the Date of Injury (DOI) in the specified section.
4. Fill in the employee’s name in the relevant field.
5. For the employer, write 'DEPT OF REHABILITATION BUSINESS ENTERPRISES PROGRAM' in the employer box.
6. Input the group number as 'CONTRC'.
7. In the employer vendor name field, enter the appropriate employer or vendor name.
8. Specify the location number in the provided section.
9. List the Third Party Administrator (TPA) indicated as 'STATE COMPENSATION INSURANCE FUND SACRAMENTO CONTRACT OFFICE, P. O. BOX 659011, SACRAMENTO, CA 95865-9011'.
10. Enter the TPA contact phone numbers in the designated spaces.
11. Indicate the medical services needed by checking the appropriate box for work-related injuries/illnesses or writing in other requests.
12. Call ahead for injury care and drug testing to ensure timely treatment, as suggested.
13. Have the employer sign in the Employer Signature section.
14. Provide the contact name and title in the respective fields.
15. Fill out the contact phone and fax numbers.
16. Detail the employee work hours in the provided fields.
17. Once all fields are completed, save your changes, and you can download, print, or share the form as needed.

Complete your documents online today for efficient management.