Objection To Treating Physicians Recommendation For Spinal Surgery Page 4
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4INSTRUCTIONS
Signing and Serving
The declarations and this form must be signed by Principals or Employees of the employer,
insurance carrier, or administrator.
This form, together with the report of the treating physician containing the recommendation for treatment
which is objected to, is to be mailed to the Administrative Director, Medical Unit, P.O. Box 71010,
Oakland, CA 94612, and copies served by mail or physical delivery or fax on the employee, employee's
attorney, and treating physician. The objection form and report may be served on the employee,
employee's attorney, and treating physician by fax, but only if prior consent has been obtained from the
recipient to be served by fax. This form may not be served on the Administrative Director by fax. This
Objection must be sent within ten (10) days of the first receipt by any of the employer, insurance carrier,
or administrator, of the treating physician's report containing the recommendation.
Declarations
The form contains two declarations to be signed under penalty of perjury. The first is a declaration
specifying the date that the report containing the treating physician's recommendation was first received
by the employer, insurance carrier, or administrator. The second declaration specifies the date and
manner of serving of the objection.
The form includes two versions of the declaration specifying the date of receipt of the report. Only one
version needs to be completed. Version A shall be completed by an employee having personal
knowledge of the facts of when the report was received, such as the person who opened the mail. Version
B shall be completed by an employee who knows from the date stamp when the report was received, if all
mail to the firm is date-stamped on the date it is received, the signer is readily knowledgeable about the
policy, the policy is consistently followed, and the report bears a legible date stamp.
The declaration regarding service of the objection must be signed by the person having knowledge of how
the report was served.
DWC Form 233
4
May 2007
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