STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF WORKERS’ COMPENSATION
ADMINISTRATIVE DIRECTOR
Post Office Box 420603
San Francisco, CA 94142
PETITION FOR CHANGE OF PRIMARY TREATING PHYSICIAN
(LABOR CODE § 4603 & TITLE 8, CALIFORNIA CODE OF REGULATIONS, § 9786)
(Print or Type Names and Addresses)
WCAB Case Nos. (If any):
:
EMPLOYEE
EMPLOYEE’S ADDRESS:
:
EMPLOYEE’S ATTORNEY
EMPLOYEE’S ATTORNEY’S ADDRESS
:
EMPLOYER
:
EMPLOYER’S ADDRESS
:
CLAIMS ADMINISTRATOR
CLAIMS ADMINISTRATOR’S ADDRESS:
:
CLAIMS ADMINISTRATOR’S CLAIM NUMBER(S)
NAME OF PRIMARY TREATING PHYSICIAN
:
PRIMARY TREATING PHYSICIAN’S ADDRESS
PHYSICIAN PANEL: List below the NAMES, ADDRESSES and MEDICAL SPECIALTIES (e.g.-orthopedics, cardiology, etc.) of
a panel of FIVE (5) physicians (to include one chiropractor if the employee is being treated by a chiropractor) available to
provide treatment of the employee’s injury in the event this petition is granted.
1.
2.
3.
4.
5.
PART A
1
DWC Form 280 (Part A) (1/01)