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Predesignated
Physicians Forms
Caltech
provides medical treatment to employees who have accepted
workers' compensation claims. However, employees have the
right to name either a personal physician, personal
chiropractor, or personal acupuncturist, who will
provide medical treatment in the event of a work-related
injury. If
you wish to predesignate a personal physician, chiropractor, or
acupuncturist, please complete the following forms:
1.
The Predesignated Physician/Chiropractor/Acupuncturist Request
form should be completed and signed by you.
2.
The appropriate Criteria for Predesignation form should be
reviewed and signed by the physician, chiropractor or
acupuncturist that you have predesignated.
Predesignated
Physician/Chiropractor/Acupuncturist Request (MS
Excel) (PDF)
Personal
Chiropractor -- Criteria for Predesignation
(MS Excel) (PDF) Personal
Acupuncturist -- Criteria for Predesignation (MS
Excel) (PDF) Personal
Physician -- Criteria for Predesignation
(MS Excel)
(PDF)
Please
return both forms to the Disability and Leave Administration
Unit, Mail Code 168-84. If the forms are incomplete, if you
fail to return both forms, or if your
physician/chiropractor/acupuncturist does not meet the
predesignated requirements, your request may be disapproved.
The Predesignation forms must be on file in the Disability and
Leave Unit prior to an injury occurring. If
there are any questions, contact the Disability and Leave
Administration Unit at (626) 395-4577 or (626) 395-8382.
Please Note: You must have Adobe Acrobat Reader to access the forms that
are in .pdf format. There is no charge to download this
program. It is free.
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