Objection To Treating Physicians Recommendation For Spinal Surgery Page 2
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4Date that the treating physician’s recommendation for this procedure was first received by any of
employer, insurance carrier, administrator:
Name of entity which received it on that date:
Type of entity (employer, insurance carrier, or administrator):
NAME OF PERSON SIGNING THIS OBJECTION:
Name:
Company:
MAILING ADDRESS: Street
City
State
Zip Code
Telephone:
Fax Number:
E-mail:
Reason(s) for this objection, specific to this employee:
Declaration Regarding Receipt of Report – SEE INSTRUCTIONS
Version A
I declare under penalty of perjury of the laws of the State of California that:
1. I am employed by _____________________________________.
2. The enclosed physician's report was first received by the employer, insurance carrier or administrator, the name of which
firm is ____________________________________________________________________, on ______________________.
(date)
3. I have personal knowledge of the above facts.
__________________________________________
__________________
(Signature of Declarant)
(date)
Version B
I declare under penalty of perjury of the laws of the State of California that:
1. I am employed by _____________________________________.
2. The enclosed physician's report was first received by the employer, insurance carrier or administrator, the name of which
firm is ____________________________________________________________________, on ______________________.
(date)
3. The firm stated in (2), above, has a written policy of date-stamping every piece of mail on the date it is delivered to its
office; this policy is consistently followed; I am knowledgeable about this policy, and the report bears a date stamp showing
that it was received in the firm's office on _______________________.
(date)
I have personal knowledge of the facts in (1) and (3), above, and as to the facts in (2), above, I am informed and believe them
to be true.
_________________________________________
__________________
(Signature of Declarant)
(date)
_________________________________________ _________________________
__________________
(Signature of Person Executing Form)
(Title)
(date)
DWC Form 233
2
May 2007
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