Objection To Treating Physicians Recommendation For Spinal Surgery
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State of California
Department of Industrial Relations
Division of Workers’ Compensation
OBJECTION TO TREATING PHYSICIAN'S
RECOMMENDATION FOR SPINAL SURGERY
EMPLOYEE
Last Name
First Name
Other names/initials
Social Security Number
Date of Injury
W.C.A.B. Case No.
Claim No. (If Available)
Telephone (If Available)
Fax No. (If Available)
RESIDENCE ADDRESS: Street
City
State
Zip Code
EMPLOYER
Name
MAILING ADDRESS: Street
City
State
Zip Code
Insurance Carrier:
Claims Administrator:
Company providing utilization review:
Employer health care provider:
EMPLOYEE’S ATTORNEY
Name
MAILING ADDRESS: Street
City
State
Zip Code
Telephone:
Fax Number:
TREATING PHYSICIAN
Last Name:
First Name :
Other names/initials:
MAILING ADDRESS: Street
City
State
Zip Code
Telephone:
Fax Number:
E-mail:
Physician’s Medical Group:
Independent Practice Association:
Exact procedure which is being objected to:
Name of facility or institution at which the proposed procedure is to be performed:
Name of facility or institution at which an alternative procedure (if any) recommended by the
employer, employer health care provider, carrier, or administrator is proposed to be performed:
DWC Form 233
1
May 2007
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