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Use this form for an employee to elect to receive medical treatment from his personal physician in case of an industrial injury or illness. Employers are required by law to provide all employees with an opportunity to pre-designate a physician for purposes of medical treatment in the event of a workplace injury. The form provides employees notice of their rights and doctor’s consent.
CalChamber Members
If you are a CalChamber member, you get this form -- and many more -- for free when you log in to HRCalifornia.com. Not a member and want this form for free? Learn more about the many benefits of membership.Product Features
- Easy-to-use, fill-in-the-blank format
- Downloadable, RTF file for you to personalize
- Sample file
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