(8 C.C.R. §9783)

TO:  (Employer's Name)

DOCTOR/MEDICAL GROUP PREDESIGNATED   If I experience a work-related injury or illness, I hereby choose to be treated by the following doctor (M.D./D.O.) or medical group:   NAME:   ADDRESS:   TELEPHONE NUMBER:

EMPLOYEE INFORMATION   NAME:   ADDRESS:     SIGNATURE:   DATE:

PHYSICIAN AGREEMENT   (TO BE COMPLETED BY PHYSICIAN OR DESIGNATED EMPLOYEE OF PHYSICIAN OR MEDICAL GROUP)   By signing below, I agree to the above predesignation.   DOCTOR'S SIGNATURE:   DATE: