Pre-Designation Form

This is a form that was created by the Division of Workers' Compensation, consistent with Labor Code Section 4600(d), to allow an injured worker to predesignate a physician prior to an industrial injury.

The form itself lists the requirements to be able to predesignate a physician. If a physician was properly predesignated before an industrial injury, then an injured worker can go to that physician instead of a company selected physician. This applies whether there is a Medical Provider Network (MPN) in place or not.

It is imperative that your doctor sign the form, and that when you give it to your employer you (1) obtain a written confirmation that the employer acknowledged receipt of this form and (2) request that a copy of the form be kept in your personnel file.