California employees who want their own doctor to treat a future work injury give this notice to the employer before any injury happens. It names the personal physician or medical group and the employee's nonoccupational health plan. The physician's signature confirms agreement to be predesignated; without it, other proof of that agreement is needed under 8 CCR 9780.1(a)(3).
The employee completes and signs the notice section. The physician, or a designated employee of the physician or medical group, signs the line reading 'Physician: I agree to this Predesignation'.
Download the current version from the source each time; forms change without notice.
Notice of Predesignation of Personal Physician
Aviso de Designación Previa de Médico Personal
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No, the physician is not required to sign. But if neither the physician nor a designated employee of the physician or medical group signs, other documentation of the physician's agreement to be predesignated is required under Title 8, California Code of Regulations, section 9780.1(a)(3).
Yes. DWC publishes a Spanish version titled Designación previa de médico personal alongside the English form. Both carry the same eligibility conditions, employee notice section and physician agreement line, so an employee can complete whichever version they read best.
A personal medical doctor (MD), doctor of osteopathic medicine (DO) or qualifying medical group. The doctor must be the employee's regular physician, must have directed their treatment and keep their records, and must agree before the injury to treat work injuries or illnesses.