Get Physician Pre-design.. - Cal Poly Pomona - Csupomona

Filling out the Physician Pre-Designation form is an important step for individuals who wish to have their personal physician treat them for work-related injuries or illnesses. This guide provides clear and detailed instructions to support users in completing the form accurately and efficiently.

Follow the steps to complete the Physician Pre-Designation form

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. In the first section, enter your full name in the 'Employee’s Name' field. Ensure to type or print clearly.
3. Fill in the 'Department' field with the name of your department. This helps in identifying your workplace.
4. Provide your extension number in the corresponding field for easy communication.
5. In the following section, write the name of your chosen physician in the 'I choose to be treated by' field.
6. Indicate whether your physician is a Medical Doctor (M.D.) or a Doctor of Osteopathic Medicine (D.O.) by marking the appropriate option.
7. Complete the contact information of your chosen physician, including telephone number and address, ensuring that all details are accurate.
8. Below your physician’s information, repeat your name and contact details for clarity.
9. Sign and date the form in the 'Employee Signature' field. This indicates your agreement to the pre-designation.
10. Finally, the physician must also sign and date the section confirming their agreement to the pre-designation.
11. Once all sections are completed and signed, return the form to Risk Management, CLA Bldg. 98, Room B1-35.

Complete your Physician Pre-Designation form online to ensure your medical preferences are recognized.