Dwc Time Of Hire Pamplet Form PDF Details

Recognizing the significance of employee health management and the right to personal medical choices in the wake of work-related injuries or illnesses, the DWC Time of Hire Pamphlet form serves as a critical document in the landscape of worker's compensation in California. This form empowers employees by allowing them to predetermine their healthcare provider for chiropractic or acupuncture services, should they suffer a work-related injury or illness, by notifying their employer of their preferred provider's name and business address in advance. It outlines a structured process wherein employees, whose employers or insurers do not have a Medical Provider Network, can opt for treatment from their personal chiropractor or acupuncturist after initial treatment is provided by the claims administrator's selected physician. This right, however, comes with certain restrictions, such as the limitation on chiropractic visits post-injury, highlighting the importance of understanding and navigating these rules to ensure ongoing access to preferred treatment methods. Enacted as part of the Division of Workers' Compensation’s efforts to ensure equitable medical treatment rights, the document also delineates conditions under which these changes in medical treatment can be made, demonstrating the nuanced approach taken towards managing workers' healthcare and recovery processes.

QuestionAnswer
Form NameDwc Time Of Hire Pamplet Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namescalifornia dwc form 9783 1, notice personal, ca form acupuncturist, dwc form notice

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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)

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