| TEAMSTERS LOCAL NO. 63 Doctor Designation Form |
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| Doctor Designation Form to print select File -> Print then click | |
| COMPANY: _______________________________________________________________________
FROM: ___________________________________________________________________________
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| SUBJECT: DESIGNATION OF A PERSONAL PHYSICIAN UNDER LABOR CODE §4600 |
| I WISH TO DESIGNATE DR. _______________________________________________________ AS MY PERSONAL PHYSICIAN UNDER LABOR CODE § 4600. |
| THE DOCTOR'S ADDRESS IS:
ADDRESS ________________________________________________________________________ CITY/STATE ______________________________________________________________________ PHONE ( ________ ) _________________________________
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| THIS DESIGNATION IS FOR THE PURPOSES OF TREATMENT IN THE EVENT THAT I HAVE AN INJURY WHILE IN THE PERFORMANCE OF THE DUTIES OF MY JOB. THIS DOCTOR HAS PREVIOUSLY DIRECTED MY MEDICAL TREATMENT AND RETAINS MY MEDICAL RECORDS, INCLUDING MY MEDICAL HISTORY. |
| RESPECTFULLY SUBMITTED,
SIGNATURE___________________________________
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| DATE _____________________ TIME STAMP _________________________________ |
| Print out and mail or fax to: 845 Oak Park Road., Covina, CA 91724 (626) 859-4084 Fax or 379 W. Valley Blvd. Rialto, CA 92376 (909) 877-2452 Fax |