Form 280 - Petition For Change Of Primary Treating Physician (Page 2 of 2) in pdf

Form 280 - Petition For Change Of Primary Treating Physician Page 2

Petitioner states that the following constitutes good cause for issuance of an Order Granting Petition For Change

Of Primary Treating Physician: (Additional sheets may be attached if necessary)

NOTE: Attach to this Petition any supportive evidence (medical reports, declarations, etc.) that establishes good

cause for the Petition to be granted. (See Title 8, California Code of Regulations, Section 9786)

VERIFICATION

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and

correct.

EXECUTED AT

, CALIFORNIA ON

(City)

(Date)

BY:

______________________________________

Original Signature of Petitioner’s Representative

Name of Petitioner’s Representative Preparing the Petition

Preparing the Petition

(Print or type)

(Address of Petitioner)

YOU MUST ATTACH A PROOF OF SERVICE BY MAIL DECLARATION INDICATING THAT: (1) PART A

(PETITION FOR CHANGE OF PRIMARY TREATING PHYSICIAN) AND PART B (RESPONSE TO PETITION FOR

CHANGE OF PRIMARY TREATING PHYSICIAN) OF THIS FORM AND (2) ALL SUPPORTIVE EVIDENCE WERE

MAILED TO THE EMPLOYEE OR THE EMPLOYEE’S ATTORNEY, AND THE PRIMARY TREATING PHYSICIAN.

Notice to Employee/Employee’s Attorney and Primary Treating Physician:

Pursuant to Title 8, California Code of Regulations, Section 9786(d), you may file with the

Administrative Director a RESPONSE to this petition within 20 days from the date the petition

was served on you. Your Response must be submitted using the Response to Petition for

Change of Treating Physician form which is contained in Part B on Pages 3

and 4 of this form. You may attach additional sheets as needed to the Response form

PART A

DWC Form 280 (Part A) (1/01)

Form 280 - Petition For Change Of Primary Treating Physician Page 2