| TEAMSTERS LOCAL NO. 572 Doctor Designation Form |
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| Doctor Designation Form to print select File -> Print then click -> Return to Menu | |
| COMPANY: _______________________________________________________________________
FROM: ___________________________________________________________________________ |
| SUBJECT: DESIGNATION OF A PERSONAL PHYSICIAN UNDER LABOR CODE §4600 |
| I WISH TO DESIGNATE DR. _______________________________________________________ AS MY PERSONAL PHYSICIAN UNDER LABOR CODE § 4600. |
| THE DOCTOR'S ADDRESS IS:
ADDRESS ________________________________________________________________________ CITY/STATE ______________________________________________________________________ PHONE ( ________ ) _________________________________ |
| THIS DESIGNATION IS FOR THE PURPOSES OF TREATMENT IN THE EVENT THAT I HAVE AN INJURY WHILE IN THE PERFORMANCE OF THE DUTIES OF MY JOB. THIS DOCTOR HAS PREVIOUSLY DIRECTED MY MEDICAL TREATMENT AND RETAINS MY MEDICAL RECORDS, INCLUDING MY MEDICAL HISTORY. |
| RESPECTFULLY SUBMITTED,
SIGNATURE___________________________________ |
| DATE _____________________ TIME STAMP _________________________________ |
| Print out and mail or fax to: Local 572, 450 E. Carson Plaza, Suite A, Carson, CA, 90746 Fax: (310)515-0942 |