Fillable Form 9783.1 - Notice Form For Personal Chiropractor Or Personal Acupuncturist 2014 printable pdf download

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NOTICE OF PERSONAL CHIROPRACTOR OR PERSONAL ACUPUNCTURIST

If your employer or your employer's insurer does not have a Medical Provider Network, you may be able to change

your treating physician to your personal chiropractor or acupuncturist following a work-related injury or illness. In

order to be eligible to make this change, you must give your employer the name and business address of a personal

chiropractor or acupuncturist in writing prior to the injury or illness. Your claims administrator generally has the

right to select your treating physician within the first 30 days after your employer knows of your injury or illness.

After your claims administrator has initiated your treatment with another doctor during this period, you may then,

upon request, have your treatment transferred to your personal chiropractor or acupuncturist.

NOTE: If your date of injury is January 1, 2004 or later, a chiropractor cannot be your treating physician after you

have received 24 chiropractic visits unless your employer has authorized additional visits in writing. The term

“chiropractic visit” means any chiropractic office visit, regardless of whether the services performed involve

chiropractic manipulation or are limited to evaluation and management. Once you have received 24 chiropractic

visits, if you still require medical treatment, you will have to select a new physician who is not a chiropractor. This

prohibition shall not apply to visits for postsurgical physical medicine visits prescribed by the surgeon, or physician

designated by the surgeon, under the postsurgical component of the Division of Workers’ Compensation’s Medical

Treatment Utilization Schedule.

You may use this form to notify your employer of your personal chiropractor or acupuncturist.

Your Chiropractor or Acupuncturist's Information:

_____________________________________________________________________________________________

(name of chiropractor or acupuncturist)

_____________________________________________________________________________________________

(street address, city, state, zip code)

_____________________________________________________________________________________________

(telephone number)

____________________________________________________________________________________________

Employee Name (please print):

_____________________________________________________________________________________________

Employee's Address:

_____________________________________________________________________________________________

Employee's Signature ___________________________ Date: _________

Title 8, California Code of Regulations, section 9783.1.

(Optional DWC Form 9783.1 Effective date July 1, 2014)

DWC FORM 9783.1 (7/2014)

Form 9783.1 - Notice Form For Personal Chiropractor Or Personal Acupuncturist 2014