Dwc Form 280 - Response To Petition For Change Of Primary Treating Physician 2001
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2STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF WORKERS’ COMPENSATION
ADMINISTRATIVE DIRECTOR
Post Office Box 420603
San Francisco, CA 94142
RESPONSE TO PETITION FOR CHANGE OF PRIMARY TREATING PHYSICIAN
(LABOR CODE § 4603 & TITLE 8, CALIFORNIA CODE OF REGULATIONS, § 9786(d))
(Print or type names and addresses)
WCAB Case Nos. (If any):
:
EMPLOYEE
EMPLOYEE’S ATTORNEY
:
EMPLOYER
:
CLAIMS ADMINISTRATOR
:
CLAIMS ADMINISTRATOR’S CLAIM NUMBER
NAME OF PRIMARY TREATING PHYSICIAN
The petition filed by or on behalf of the Claims Administrator does not establish good cause for the issuance of
an Order Granting Petition For Change Of Primary Treating Physician based on the following: (additional sheets
may be attached if necessary)
PART B
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DWC Form 280 (Part B) (1/01)
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