Doctors First Report Of Occupational Injury Or Illness California (Page 3 of 3) in pdf

STATE OF CALIFORNIA

DOCTOR'S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS

Physician Signature: (original signature, do not stamp)

I declare under penalty of perjury that this report is true and correct to the best of my knowledge and that I have not violated

Labor Code section 139.3.

Physician signature

Cal. License Number:

Executed at:

Date (mm/dd/yyyy):

Physician Name

Specialty:

Physician address:

Phone Number

Any person who makes or causes to be made any knowingly fraudulent material statement or material representation for the

purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony.

PRIVACY NOTICE: The Administrative Director is authorized to maintain the records of the Division of Workers' Compensation (DWC). (Cal. Lab. Code

§ 126.) The Information Practices Act of 1977 and the Federal Privacy Act require the Administrative Director to provide this notice to individuals who

submit information to the DWC pertaining to a workers' compensation claim. (Cal. Civ. Code § 1798.17; Public Law 93-579.)

The principal purpose for requesting information from injured workers, dependents, lien claimants, physician, employers or their representatives is to

administer the California workers' compensation system. Each form shows which fields are required to be completed for DWC to process the form. If a

required field in a form is incomplete or unreadable, the DWC may return the form to the individual for correction or may reject the form. Providing a social

security number is required on this form pursuant to Labor Code § 6409. If you do not provide your security number, the DWC may return the form to you for

correction or reject the form. If you do not have a social security number, indicate this in the space provided for the injured worker's social security number.

As permitted by law, social security numbers are used to help properly identify injured workers and to conduct statistical research as allowed under the Labor

Code.

As authorized by law, information furnished on this form may be given to: you, upon request; the public, pursuant to the Public Records Act; a governmental

entity, when required by state or federal law; to any person, pursuant to a subpoena or court order pursuant to any other exception in Civil Code § 1798.24.

An individual has a right of access to records containing his/her personal information that are maintained by the Administrative Director. An individual may

also amend, correct, or dispute information in such personal records. (Cal. Civ. Code §§ 1798.34-1798.3.) You may request a copy of the DWC's policies and

procedures for inspection of records at the address below. Copies of the procedures and all records are ten cents ($0.10) per page, payable in advance. (Cal.

Civ. Code § 1798.33.) Requests should be sent to: Division of Workers' Compensation- Medical Unit, P.O. Box 71010, Oakland, CA 94612. Tel: (510)

286-3700 or (800) 794.6900. Fax: (510) 622-3467.

Sheet 3 of 3

Form 5021 (Rev. 5) 10/2015