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§ 9786.1. Petition for Change of Primary Treating Physician; Response to Petition for Change of...

8 CA ADC § 9786.1BARCLAYS OFFICIAL CALIFORNIA CODE OF REGULATIONS

Barclays Official California Code of Regulations Currentness
Title 8. Industrial Relations
Division 1. Department of Industrial Relations
Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director -Administrative Rules
Article 5. Predesignation of Personal Physician; Request for Change of Physician; Reporting Duties of the Primary Treating Physician; Petition for Change of Primary Treating Physician
8 CCR § 9786.1
§ 9786.1. Petition for Change of Primary Treating Physician; Response to Petition for Change of Primary Treating Physician (DWC Form 280 (Parts A and B)).
STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF WORKERS' COMPENSATION
ADMINISTRATIVE DIRECTOR
Post Office Box 420603
San Francisco, CA 94142
PETITION FOR CHANGE OF PRIMARY TREATING PHYSICIAN
(LABOR CODE s 4603 & TITLE 8, CALIFORNIA CODE OF REGULATIONS, s 9786)
________________________________________________________________
(Print or Type Names and Addresses)
WCAB Case Nos. (If any):________________________________________
EMPLOYEE: ______________________________________________________
EMPLOYEE'S
ADDRESS ________________________________________________________
EMPLOYEE'S ATTORNEY: ___________________________________________
EMPLOYER: ______________________________________________________
EMPLOYER'S ADDRESS:_____________________________________________
CLAIMS ADMINISTRATOR: __________________________________________
CLAIMS ADMINISTRATOR'S ADDRESS _________________________________
CLAIMS ADMINISTRATOR'S CLAIM NUMBER(S): ________________________
NAME OF PRIMARY TREATING PHYSICIAN _____________________________
PRIMARY TREATING PHYSICIAN'S ADDRESS: __________________________
PHYSICIAN PANEL: List below the NAMES, ADDRESSES AND MEDICAL SPECIALTIES (e.g.-orthopedics, cardiology, etc.) of a panel of FIVE (5) physicians (to include one chiropractor if the employee is being treated by a chiropractor) available to provided treatment of the employee's injury in the event this petition is granted.
1. _____________________________________________________________
2. _____________________________________________________________
3. _____________________________________________________________
4. _____________________________________________________________
5. _____________________________________________________________
Part A.
Petitioner states that the following constitutes good cause for issuance of an Order Granting Petition For Change Of Primary Treating Physican: (Additional sheets may be attached if necessary)
NOTE: Attach to this Petition any supportive evidence (medical reports, declarations, etc.) that establishes good cause for the Petition to be granted. (See Title 8, California Code of Regulations, Section 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 Petitioner's // Name of Petitioner's
Representative Preparing // Representative Preparing the
the Petition Petition (Print or type)
________________________________________________________________
(Address of Petitioner)
________________________________________________________________
YOU MUST ATTACH A PROOF OF SERVICE BY MAIL DECLARATION INDICATING THAT: (1) PART a (PETITION FOR CHANGE OF PRIMARY TREATING PHYSICIAN) AND PART B (RESPONSE TO PETITION FOR CHANGE OF PRIMARY TREATING PHYSICIAN) OF THIS FORM AND (2) ALL SUPPORTIVE EVIDENCE WERE MAILED TO THE EMPLOYEE OR THE EMPLOYEE'S ATTORNEY, AND THE PRIMARY TREATING PHYSICIAN.
________________________________________________________________
Notice to Employee/Employee's Attorney and Primary Treating Physician:
Pursuant to Title 8, California Code of Regulations, Section 9786(d), you may file with the Administrative Director a RESPONSE to this petition within 20 days from the date the petition was served on you. Your Response must be submitted using the Response to Petition for Change of Treating Physician form which is contained in Part B on Pages 3 and 4 of this form. You may attach additional sheets as needed to the Response form.
________________________________________________________________
RESPONSE TO PETITION FOR CHANGE OF PRIMARY TREATING PHYSICIAN
(LABOR CODE s 4603 & TITLE 8, CALIFORNIA CODE OF REGULATIONS, s 9786(d)
________________________________________________________________
(Print or type names and addresses)
WCAB Case Nos. (If any):________________________________________
EMPLOYEE: ______________________________________________________
EMPLOYEE'S ATTORNEY: ___________________________________________
EMPLOYER: ______________________________________________________
CLAIMS ADMINISTRATOR: __________________________________________
CLAIMS ADMINISTRATOR'S CLAIM NUMBER(S): ________________________
NAME OF PRIMARY TREATING PHYSICIAN _____________________________
________________________________________________________________
The petition filed by or on behalf of the Claims Administrator does not establish good cause for the issuance of an Order Granting Petition For Change Of Primary Treating Physician based on the following: (additional sheets may be attached if necessary)
IMPORTANT: Attach to this Response any supportive documentary evidence (medical reports, affidavit and declaration, etc.) which established that there is not good cause for the Administrative Director to grant the Petition for Change of Primary Physician. (See Title 8, California Code of Regulations, s 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 // Name of Person Preparing
Preparing the Response // 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$u
On _____________I served a copy of this Response to Petition forChange of Treating Physician on
(date)
______________________ at __________________________________ and
(Claims Administrator or its Attorney) (address)
______________________ at __________________________________ and
(Primary Treating Physician (address)
or Employee/Employee's/
Attorney)
placing a true copy enclosed is 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
4
DWC Form 280 (Part B)(1/01)
Note: Authority cited: Sections 133, 139.5, 4603.2, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600, 4603 and 4603.2, Labor Code.
HISTORY
1. New section (DWC form 280) filed 12-22-2000; operative 1-1-2001 pursuant to Government Code section 11343.4(d) (Register 2000, No. 51).
This database is current through 6/17/22 Register 2022, No. 24
8 CCR § 9786.1, 8 CA ADC § 9786.1
End of Document