Dwc Form 280 - Response To Petition For Change Of Primary Treating Physician 2001 (Page 2 of 2) in pdf

Dwc Form 280 - Response To Petition For Change Of Primary Treating Physician 2001 Page 2

IMPORTANT: Attach to this Response any supportive documentary evidence (medical reports, affidavit and

declaration, etc.) which establishes that there is not good cause for the Administrative Director to grant the

Petition for Change of Primary Treating Physician. (See Title 8, California Code of Regulations, § 9786)

VERIFICATION

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and

correct.

EXECUTED AT

, CALIFORNIA ON

(City)

(Date)

BY:

Original

Signature of Person Preparing the Response //

Name of Person Preparing the Response (Print or type)

Address:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

NOTICE TO EMPLOYEE/EMPLOYEE’S ATTORNEY: THE PROOF OF SERVICE BY MAIL DECLARATION

BELOW MUST BE COMPLETED INDICATING A COPY OF THIS RESPONSE HAS BEEN MAILED TO THE

CLAIMS ADMINISTRATOR OR ITS ATTORNEY, AND THE PRIMARY TREATING PHYSICIAN.

NOTICE TO PRIMARY TREATING PHYSICIAN: THE PROOF OF SERVICE BY MAIL DECLARATION BELOW

MUST BE COMPLETED INDICATING A COPY OF THIS RESPONSE HAS BEEN MAILED TO THE CLAIMS

ADMINISTRATOR OR ITS ATTORNEY, AND THE EMPLOYEE OR THE EMPLOYEE’S ATTORNEY.

PROOF OF SERVICE BY MAIL

I served a copy of this Response to Petition for Change of Treating Physician on

)

(date

and

)

(Claims Administrator or its Attorney

(address)

(Primary Treating Physician or Employee/

(address)

Employee's Attorney)

placing a true copy enclosed in a sealed envelope, addressed as indicated above and with postage fully prepaid,

in the U.S. Mail at_________________________, California. I declare under penalty of perjury under the

laws of the State of California that the foregoing is true and correct.

Original Signature of Declarant

Name of Declarant (Print or Type)

PART B

DWC Form 280 (Part B) (1/01)

Dwc Form 280 - Response To Petition For Change Of Primary Treating Physician 2001 Page 2