Get Kaiser On The Job & Predesignation Form(pdf, 2mb) - City Of Alameda

Filling out the Kaiser On The Job & Predesignation Form is an essential aspect of reporting work-related injuries or illnesses. This guide provides clear, step-by-step instructions to help you complete the form online efficiently and accurately.

Follow the steps to successfully complete your form.

1. Press the ‘Get Form’ button to access the Kaiser On The Job & Predesignation Form. Open it in your online editing tool.
2. In the first section, fill in your employer's name as indicated: UCLA Health System/Santa Monica UCLA Medical Center/Semel Institute for Neuroscience and Human Behavior (NPH).
3. Next, provide your employee ID number or Social Security number in the appropriate field.
4. Indicate your chosen physician's name (M.D. or D.O.) and their office address, including street, city, state, and ZIP code.
5. Include your physician's telephone number and specialty, if known.
6. Fill out your name and address as the employee, along with the date, and ensure you sign the form.
7. The physician must complete their section by printing their name and signing the form. If they choose not to sign, additional documentation may be required.
8. Optional information, such as the office manager’s contact details and physician tax ID, can be included to facilitate communication but is not mandatory.
9. If you agree to let your employer contact your physician, sign in the indicated area. Otherwise, proceed to the submission.
10. Once completed, save any changes made to the form. You can then download, print, or share the form as required.

Complete your forms online to ensure a smooth process for reporting work-related injuries.