Form Wcl-18 - Pre-Designated Physician Form
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1CITY OF LOS ANGELES
WORKERS’ COMPENSATION
PRE-DESIGNATED PHYSICIAN FORM
As a City employee and pursuant to Labor Code Sec. 4600(d)(1), you may pre-designate your personal physician
to treat future on-the-job injuries. If you do not pre-designate, the City will refer you to an appropriate physician.
REQUIREMENTS:
v To treat your on-the-job injury, your pre-designated physician must be on file with the City before your date of
injury.
v Pursuant to Labor Code Section 4600(d)(2), a personal physician shall meet all of the following conditions:
(A) The physician is the employee’s regular physician and surgeon, licensed pursuant to Chapter 5
(commencing with Section 2000) of Division 2 of the Business and Professions Code.
(B) The physician is the employee’s primary care physician and has previously directed the medical treatment
of the employee, and who retains the employee’s medical records, including his/her medical history.
(C) The physician agrees to be pre-designated.
v Complete the form below in its entirety, sign and date the form. If you pre-designate Kaiser Permanente,
you do not have to complete Section 2 below. If you pre-designate a physician who is not a doctor with
Kaiser Permanente, you must complete Sections 1 and 2 below.
v Update your pre-designation if you change primary care physician. The pre-designated physician must be your
primary care physician prior to your date of injury.
v Submit the completed form to: City of Los Angeles Personnel Department, Workers’ Compensation Division,
700 E. Temple Street, Room 210, Los Angeles, CA 90012, Mail Stop #391, (213) 473-3400.
SECTION 1
Employee Name: _____________________ Employee SS#: ______________ Department: _________________
Employee Work Phone: (
)____________________ Employee Home Phone: (
)_____________________
Personal Physician Name: ______________________________________________________________________
Physician named above is my primary care physician under the following health plan provider:
¨ Blue Cross
¨ Kaiser Permanente
¨ Other
__________________________________________________
Employee Declaration:
In the event that I receive an injury on duty, I designate my personal physician (as defined in Labor Code Section
4600(d)(2)) identified above as my workers’ compensation physician.
He/she is my regular and primary care
physician, retains my medical records, is willing to complete the required workers’ compensation forms, and is
willing to keep the Workers’ Compensation Division informed of my medical status.
Employee Signature: ________________________________________________ Date: ____________________
SECTION 2
(Do not complete this section if pre-designating Kaiser Permanente.)
Physician Specialty: ___________________________________________________________________________
Physician Address: ____________________________________________________________________________
Physician Phone: (
)________________________________________________________________________
Personal Physician Declaration:
v I am the personal physician (as defined in Labor Code Section 4600(d)(2)) for the City employee named above.
v I am this employee’s regular and primary care physician.
v I retain this employee’s medical records.
v I agree to be this employee’s pre-designated physician, complete all required workers’ compensation forms,
and keep the Workers’ Compensation Division informed of the employee’s status regarding any occupational
related treatment.
Physician Signature: ________________________________________________ Date: ____________________
Workers’ Compensation Analyst Approval: _____________________________ Date: ____________________
WCL-18 (7/23/04)
y:admin/pre-d/card
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