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Get Personal Chiropractor Predesignation Form - The Supply Center
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How to fill out the Personal Chiropractor Predesignation Form - The Supply Center online
Filling out the Personal Chiropractor Predesignation Form is crucial for ensuring you can receive chiropractic treatment from your chosen provider in the event of a work-related injury. This guide will walk you through the steps needed to complete the form accurately and efficiently online.
Follow the steps to fill out the Personal Chiropractor Predesignation Form.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Complete the form by filling in your name, date, and the name of your employer at the designated fields.
- Designate your chosen chiropractor by filling in their name and including their professional title (DC) in the specified area.
- Sign the form to confirm your designation of the chiropractor and ensure the date is written as well.
- Provide the completed form to your personnel representative and ask them to sign and date it upon receipt.
- Request that the personnel representative places the form in your personnel file and retain two copies for yourself: one for your records and another to mail to your chiropractor's office.
- Ensure to keep your copy of the form safe, as this might be important in protecting your right to chiropractic care.
Complete your Personal Chiropractor Predesignation Form online today to secure your healthcare preferences.
Pursuant of Title 8, California Code of Regulation, section 9780.1(a)(3): The employee's personal physician agrees to be predesignated prior to the injury. The personal physician may sign the optional predesignation form (DWC Form 9783) as documentation of such agreement.
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