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Note: Authority cited: Sections 133, 4600.3, 4600.5, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600, 4600.3 and 4600.5, Labor Code.
s 9779.4. DWC Form 1194.
CHOOSING MEDICAL CARE FOR WORK-RELATED INJURIES and ILLNESSES
California law requires your employer to provide and pay for medical treatment if you are injured at work. Your employer has chosen to provide this medical care by using a health plan called a Workers' Compensation Health Care Organization, or HCO. This form gives you information about the HCO program, and describes your rights in choosing medical care for work-related injuries and illnesses.
What is an HCO?
A Workers' Compensation Health Care Organization is an organization which has been certified by the State of California Division of Workers' Compensation to provide health care to injured workers. HCOs must meet the quality and service standards set by the Division of Workers' Compensation. They must have health care providers who understand the workers' compensation system and occupational health care. The HCO must be able to work with employers and workers to improve worksite health and safety.
If you choose an HCO, the HCO will coordinate all aspects of the care for your work injury, including working with your employer to help you get back to work in a job that will not make the injury worse. The HCO must provide information on the services they provide to injured workers and must answer your questions and complaints. By choosing an HCO, you may help your employer save money. There is no cost to you in choosing an HCO.
Choosing an HCO
Your employer has offered you enrollment in an HCO. If your employer's workers' compensation insurance company owns or controls this HCO, your employer must tell you this during the enrollment process. Your employer must give you information about the HCO before you make a choice.
If you choose to enroll in the HCO, you must use the HCO for any medical treatment you need as a result of a work injury for at least 90 days after the injury. If you choose an HCO and your employer pays for at least one-half of your health insurance (for non-work injuries), then you must use the HCO for at least 180 days after a work injury. In some HCOs, your own personal physician, personal chiropractor or personal acupuncturist for your regular health care is available to treat you for work injuries/illnesses.
Choosing Your Own Doctor - Not in an HCO
If you do not want to be treated by the HCO after a work injury, you can "designate" your own personal physician, personal chiropractor or personal acupuncturist who has treated you before and who has your medical records. If you choose your own personal physician, personal chiropractor or personal acupuncturist, you may go to him or her any time for treatment of a work injury.
DWC Form 1194: front (rev. 1/03)
MAKING YOUR CHOICE For Workers' Compensation Health Care
Use this form to choose how you want to get medical care if you have a work-related injury or illness. You may choose the Workers' Compensation Health Care Organization offered by your employer, or you may designate your own personal physician, personal chiropractor or personal acupuncturist. If you choose to designate your own personal physician, personal chiropractor or personal acupuncturist, you should do so in the space provided below. If you do not make one of these choices, your employer will enroll you in the HCO in order for you to receive treatment for a work injury or illness.
If you have questions about HCOs or medical treatment after a work injury, you may call an Information and Assistance officer. Find the telephone number in the phone book listed under State of California, Department of Industrial Relations, Division of Workers Compensation. If you have concerns, complaints or questions regarding a specific HCO or the enrollment process you can call 1- 800-277-1767.
__________ __________
THIS IS AN IMPORTANT LEGAL DOCUMENT THAT AFFECTS YOUR RIGHTS IF YOU HAVE A WORK INJURY. I want to enroll in an HCO for my medical care for any work-related injury or illness. I have received information about the Health Care Organization offered by my employer and want to enroll in that HCO. __________ __________ __________ I do not want to enroll in an HCO. I want my personal physician, personal chiropractor or personal acupuncturist to treat me for any work-related injury or illness. My personal physician, personal chiropractor or personal acupuncturist is: __________ __________ __________ (Write in the name, and address and telephone number of your personal physician, personal chiropractor or personal acupuncturist.) I do not want to enroll in an HCO or designate a personal physician, personal chiropractor or personal acupuncturist to treat me for any work-related injury or illness. I understand that my employer will enroll me in the HCO for treatment of any work-related injury or illness.
__________ __________ __________ __________
(Print) Name of Employee Signature __________ __________ Date Signed
DWC Form 1194: back (rev. 1/03)
Note: Authority cited: Sections 133, 4600.5, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600 and 4600.5, Labor Code.
s 9779.45. Minimum Periods of Enrollment.
Pursuant to Labor Code Section 4600.3:
(a) An employee whose employer does not offer non-occupational health coverage under a plan established pursuant to collective bargaining, and does not offer to pay more than one-half the cost of non-occupational health coverage for that employee under another plan, may be treated for occupational injuries and illnesses by a physician of the employee's choosing after 90 days from the date the injury was reported.
(b) An employee whose employer offers non-occupational health coverage under a plan established pursuant to collective bargaining, or offers to pay more than one-half the cost of non-occupational health coverage for that employee under another plan, may be treated for occupational injuries and illnesses by a physician of the employee's choosing after 180 days from the date the injury was reported or upon the date of contract renewal or open enrollment of the health care organization, whichever occurs first, but in no case until 90 days from the date the injury was reported.
Note: Authority cited: Sections 133, 4600.3, 4600.5, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600, 4600.3 and 4600.5, Labor Code.
s 9779.5. Reimbursement of Costs to the Administrative Director; Obligation to Pay Share of Administrative Expense.
(a) Each organization certified under this article shall pay to the administrative director an amount as estimated by the administrative director for the ensuing fiscal year, as a reimbursement of a share of all costs and expenses, including routine on-site surveys, data collection and dissemination and overhead, reasonably incurred in the administration of this article and not otherwise recovered by the administrative director under this article or from the Worker's Compensation Managed Care Fund. The amount shall be assessed annually on or before April 15 and may be paid to the Workers' Compensation Managed Care Fund in two equal installments. The first installment shall be paid on or before July 1 of each year and the second installment shall be paid on or before December 15 of each year.
(1) Annual Assessment: The assessment shall be calculated on the basis of the number of enrollees in each individual HCO. Each HCO will be assessed a sum equivalent to $1.00 per enrollee, based on the number of enrollees enrolled in the HCO on December 31 of the prior calendar year.
(2) Loan Repayment Surcharge: Each HCO will be assessed an annual surcharge of fifty cents per enrollee, based on the number of enrollees in the HCO on December 31 of the prior claendar year, until the loan is fully repaid. This surcharge will be used solely to reimburse the general fund for the loan made to the Workers' Compensation Managed Care Fund. The surcharge shall be assessed at this level for up to five years, commencing with the 1999 assessment. If the general fund loan has not been fully repaid after five years, the annual surcharge for each HCO shall be adjusted the following three years to fully repay the loan as follows:
2004: (One-third of outstanding loan balance) divided by (total number of enrollees in all certified HCOs) times (number of enrollees in HCO)
2005: (One-half of outstanding loan balance) divided by (total number of enrollees in all certified HCOs) times (number of enrollees in HCO)
2006: (Total outstanding loan balance) divided by (total number of enrollees in all certified HCOs) times (number of enrollees in HCO)
(b) Non-routine audits conducted in response to complaints will be charged based on the actual cost for performing the audit. The invoice will be sent within sixty days of the completion of the audit and shall be paid within 30 calendar days after the billing date.
(c) In no case shall the reimbursement, payment, or other fee authorized by this section exceed the cost, including overhead, reasonably incurred in the administration of this article.
Note: Authority cited: Sections 133, 4600.5, 4600.7, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600 and 4600.5, Labor Code.
s 9779.8. Copies of Documents.
Fees for copies of documents will be charged as set forth in Section 9990. Any request for copies of documents must include payment of fees by check or money order made payable to the Workers' Compensation Managed Care Fund.
Note: Authority: Sections 133, 4600.5, 4600.7, 4603.5, 5307.3, Labor Code. Reference: Sections 4600, 4600.5, Labor Code.
s 9779.9. Late Payment.
Failure to pay fees and assessments within sixty days after the date due pursuant to this section shall allow the administrative director to charge a late payment fee for any outstanding amount at a rate of ten percent after sixty days or one hundred dollars, whichever is greater. In addition, after sixty days a late fee of ten percent per year shall be assessed on any outstanding amount. In addition, the administrative director may suspend or revoke certifications of HCOs which fail to pay fees and assessment in a timely manner.
Note: Authority: Sections 133, 4600.5, 4600.7, 4603.5, 5307.3, Labor Code. Reference: Sections 4600, 4600.5, Labor Code.
s 9780. Definitions.
As used in this Article:
(a) "Claims Administrator" means a self-administered insurer providing security for the payment of compensation required by Divisions 4 and 4.5 of the Labor Code, a self-administered self-insured employer, a self-administered joint powers authority, a self-administered legally uninsured, or a third-party claims administrator for a self-insured employer, insurer, legally uninsured employer, or joint powers authority.
(b) "Emergency health care services" means health care services for a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to place the patient's health in serious jeopardy.
(c) "Facility" means a hospital, clinic or other institution capable of providing the medical, surgical, chiropractic or hospital treatment which is reasonably required to cure or relieve the employee from the effects of the injury.
(d) "First aid" is any one-time treatment, and a follow-up visit for the purpose of observation of minor scratches, cuts, burns, splinters, etc., which do not ordinarily require medical care. Such one-time treatment, and follow-up visit for the purpose of observation, is considered first aid, even though provided by a physician or registered professional personnel.
(e) "Nonoccupational group health coverage" means coverage for nonoccupational health care that the employer makes available to the employee, including, but not limited to, a Taft Hartley or Employee Retirement Income Security Act (ERISA) trust, or a health plan negotiated between a union or employee's association and the employer or employer's association.
(f)(1) the employee's regular physician and surgeon, licensed pursuant to Chapter 5 (commencing with section 2000) of Division 2 of the Business and Professions Code, (2) who has been the employee's primary care physician, and has previously directed the medical treatment of the employee, and (3) who retains the employee's medical records, including the employee's medical history.
(g) "Primary Care Physician" means a physician who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. A primary care physician shall be either a physician who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist, or family practitioner.
(h) "Reasonable geographic area" within the context of Labor Code section 4600 shall be determined by giving consideration to:
(1) The employee's place of residence, place of employment and place where the injury occurred; and
(2) The availability of physicians in the fields of practice, and facilities offering treatment reasonably required to cure or relieve the employee from the effects of the injury;
(3) The employee's medical history;
(4) The employee's primary language.
Note: Authority cited: Sections 59, 133 and 4603.5, Labor Code. Reference: Section 4600, Labor Code.
s 9780.1. Employee's Predesignation of Personal Physician.
(a) An employee may be treated for an industrial injury in accordance with section 4600 of the Labor Code by a personal physician that the employee predesignates prior to the industrial injury if the following three conditions are met:
(1) Notice of the predesignation of a personal physician is in writing, and is provided to the employer prior to the industrial injury for which treatment by the personal physician is sought. The notice shall include the personal physician's name and business address. The employee may use the optional predesignation form (DWC Form 9783) in section 9783 for this purpose.
(2) The employer provides: (i) nonoccupational group health coverage in a health care service plan, licensed pursuant to Chapter 2.2 (commencing with section 1340) of Division 2 of the Health and Safety Code, or (ii) nonoccupational health coverage in a group health plan or a group health insurance policy as described in section 4616.7 of the Labor Code. The employer's provision of health coverage as defined herein is sufficient to meet this requirement, regardless of whether the employee accepts or participates in this health coverage.
(3) The employee's personal physician agrees to be predesignated prior to the injury. The personal physician may sign the optional predesignation form (DWC Form 9783) in section 9783 as documentation of such agreement. The physician may authorize a designated employee of the physician to sign the optional predesignation form on his or her behalf. If the personal physician or the designated employee of the physician does not sign a predesignation form, there must be other documentation that the physician agrees to be predesignated prior to the injury in order to satisfy this requirement.
(b) If an employee has predesignated a personal physician prior to the effective date of these regulations, such predesignation shall be considered valid if the conditions in subdivision (a) have been met.
(c) Where an employer or an employer's insurer has a Medical Provider Network pursuant to section 4616 of the Labor Code, an employee's predesignation which has been made in accordance with this section shall be valid and the employee shall not be subject to the Medical Provider Network.
(d) Where an employee has made a valid predesignation pursuant to this section, and where the employer or employer's insurer has a Medical Provider Network, any referral to another physician for other treatment need not be within the Medical Provider Network.
(e) An employer who qualifies under (a)(2) of this section shall notify its employees of all of the requirements of this section and provide its employees with an optional form for predesignating a personal physician, in accordance with section 9880. The employer may use the predesignation form (DWC Form 9783) in section 9783 for this purpose.
(f) Unless the employee agrees, neither the employer nor the claims administrator shall contact the predesignated personal physician to confirm predesignation status or contact the personal physician regarding the employee's medical information or medical history prior to the personal physician's commencement of treatment for an industrial injury.
(g) Where the employer has been notified of an employee's predesignation of a personal physician in accordance with this section and where the employer becomes liable for an employee's medical treatment, the claims administrator shall:
(1) authorize the predesignated physician to provide all medical treatment reasonably required to cure or relieve the injured employee from the effects of his or her injury;
(2) furnish the name and address of the person to whom billing for treatment should be sent;
(3) where there has been treatment of an injury prior to commencement of treatment by the predesignated physician, arrange for the delivery to the predesignated physician of all medical information relating to the claim, all X-rays, the results of all laboratory studies done in relation to the injured employee's treatment; and
(4) provide the physician with (1) the fax number, if available, to be used to request authorization of treatment plans; (2) the complete requirements of section 9785; and (3) the forms set forth in sections 9785.2 and 9785.4. In lieu of providing the materials required in (2) and (3) immediately above, the claims administrator may refer the physician to the Division of Workers' Compensation's website where the applicable information and forms can be found at http://www.dir.ca.gov/DWC/dwc_home_page.htm.
(h) Notwithstanding subdivision (g), the employer shall provide first aid and appropriate emergency health care services reasonably required by the nature of the injury or illness. Thereafter, if further medical treatment is reasonably required to cure or relieve the injured employee from the effects of his or her injury, the claims administrator shall authorize treatment with the employee's predesignated personal physician in accordance with subdivision (g).
(i) If documentation of a physician's agreement to be predesignated has not been provided to the employer as of the time of injury, treatment shall be provided in accordance with Labor Code section 4600, or Labor Code section 4616, if the employer or insurer has established a Medical Provider Network, as though no predesignation had occurred. Upon provision of the documented agreement that was made prior to injury that meets the conditions of Labor Code section 4600(d), the employer or claims administrator shall authorize treatment with the employee's predesignated physician as set forth in subdivision (g).
Note: Authority cited: Sections 59, 133 and 4603.5, Labor Code. Reference: Sections 3551, 4600 and 4616, Labor Code.
s 9780.2. Employer's Duty to Provide First Aid and Emergency Treatment.
Note: Authority cited: Sections 124, 127, 133, 138.2, 138.3, 138.4, 139, 139.5, 139.6, 4600, 4601, 4602, 4603, 4603.2, 4603.5, 5307.3, 5450, 5451, 5452, 5453, 5454, and 5455, Labor Code. Reference: Chapters 442, 709, and 1172, Statutes of 1977; Chapter 1017, Statutes of 1976.
s 9781. Employee's Request for Change of Physician.
(a) This section shall not apply to self-insured and insured employers who offer a Medical Provider Network pursuant to section 4616 of the Labor Code.
(b) Pursuant to section 4601 of the Labor Code, and notwithstanding the 30 day time period specified in subdivision (c), the employee may request a one time change of physician at any time.
(1) An employee's request for change of physician pursuant to this subdivision need not be in writing. The claims administrator shall respond to the employee in the manner best calculated to inform the employee, and in no event later than 5 working days from receipt of said request, the claims administrator shall provide the employee an alternative physician, or if the employee so requests, a chiropractor or acupuncturist.
(2) Notwithstanding subdivision (a) of section 9780.1, if an employee requesting a change of physician pursuant to this subdivision has notified his or her employer in writing prior to the date of injury that he or she has either a personal chiropractor or a personal acupuncturist, and where the employee so requests, the alternative physician tendered by the claims administrator to the employee shall be the employee's personal chiropractor or personal acupuncturist as defined in subdivisions (b) and (c), respectively, of Labor Code section 4601. The notification to the employer must include the name and business address of the chiropractor or acupuncturist. The employer shall notify its employees of the requirements of this subdivision and provide its employees with an optional form for notification of a personal chiropractor or acupuncturist, in accordance with section 9880. DWC Form 9783.1 in section 9783.1 may be used for this purpose.
(3) Except where the employee is permitted to select a personal chiropractor or acupuncturist as defined in subdivisions (b) and (c), respectively, of Labor Code section 4601, the claims administrator shall advise the employee of the name and address of the alternative physician, or chiropractor or acupuncturist if requested, the date and time of an initial scheduled appointment, and any other pertinent information.
(c) Pursuant to section 4600, after 30 days from the date the injury is reported, the employee shall have the right to be treated by a physician or at a facility of his or her own choice within a reasonable geographic area.
(1) The employee shall notify the claims administrator of the name and address of the physician or facility selected pursuant to this subdivision. However, this notice requirement will be deemed to be satisfied if the selected physician or facility gives notice to the claims administrator of the commencement of treatment or if the claims administrator receives this information promptly from any source.
(2) If so requested by the selected physician or facility, the employee shall sign a release permitting the selected physician or facility to report to the claims administrator as required by section 9785.
(d) When the claims administrator is notified of the name and address of an employee-selected physician or facility pursuant to subdivision (c), or of a personal chiropractor or acupuncturist pursuant to paragraph (2) of subdivision (b), the claims administrator shall:
(1) authorize such physician or facility or personal chiropractor or acupuncturist to provide all medical treatment reasonably required pursuant to section 4600 of the Labor Code;
(2) furnish the name and address of the person to whom billing for treatment should be sent;
(3) arrange for the delivery to the selected physician or facility of all medical information relating to the claim, all X-rays and the results of all laboratory studies done in relation to the injured employee's treatment; and
(4) provide the physician or facility with (1) the fax number, if available, to be used to request authorization of treatment plans; (2) the complete requirements of section 9785; and (3) the forms set forth in sections 9785.2 and 9785.4. In lieu of providing the materials required in (2) and (3) immediately above, the claims administrator may refer the physician or facility to the Division of Workers' Compensation's website where the applicable information and forms can be found at http://www.dir.ca.gov/DWC/dwc_home_ page.htm.
Note: Authority cited: Sections 133 and 4603.5, Labor Code. Reference: Sections 3551, 4600 and 4601, Labor Code.
s 9782. Notice to Employee of Right to Choose Physician.
(a) Except for an employer who has established a Medical Provider Network, or an employer whose insurer has established a Medical Provider Network, every employer shall advise its employees in writing of an employee's right (1) to request a change of treating physician if the original treating physician is selected initially by the employer pursuant to Labor Code section 4601, and (2) to be treated by a physician of his or her own choice 30 days after reporting an injury pursuant to subdivision (c) of Labor Code 4600.
(b) Every employer shall advise its employees in writing of an employee's right to predesignate a personal physician pursuant to subdivision (d) of Labor Code section 4600, and section 9780.1.
(c) The notices required by this section shall be provided in accordance with section 9880 and posted in accordance with section 9881.
Note: Authority cited: Sections 133 and 4603.5, Labor Code. Reference: Sections 3550, 3551, 4600, 4601 and 4616, Labor Code.
s 9783. DWC Form 9783 Predesignation of Personal Physician.
PREDESIGNATION OF PERSONAL PHYSICIAN
In the event you sustain an injury or illness related to your employment, you may be treated for such injury or illness by your personal medical doctor (M.D.) or doctor of osteopathic medicine (D.O.) if:
your employer offers group health coverage;
the doctor is your regular physician, who shall be either a physician who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist, or family practitioner, and has previously directed your medical treatment, and retains your medical records;
prior to the injury your doctor agrees to treat you for work injuries or illnesses;
prior to the injury you provided your employer the following in writing: (1) notice that you want your personal doctor to treat you for a work-related injury or illness, and (2) your personal doctor's name and business address. You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met.
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN
Employee: Complete this section.
To: ____________________________ (name of employer) If I have a work-related injury or illness, I choose to be treated by:
__________ (name of doctor)(M.D., D.O.)
__________ __________(street address, city, state, ZIP)
__________(telephone number)
Employee Name (please print): _________ ____________________
Employee's Address: ______________________________
Employee's Signature ____________________ Date: __________
Physician: I agree to this Predesignation:
Signature: ____________________ Date: __________
(Physician or Designated Employee of the Physician)
The physician is not required to sign this form, however, if the physician or designated employee of the physician does not sign, other documentation of the physician's agreement to be predesignated will be required pursuant to Title 8, California Code of Regulations, section 9780.1(a)(3).
Title 8, California Code of Regulations, section 9783. (Optional DWC Form 9783-Effective date March 2006)
Note: Authority cited: Sections 133, 4603.5 and 5307.3, Labor Code. Reference: Section 4600, Labor Code
s 9783.1. DWC Form 9783.1 Notice of Personal Chiropractor or Personal Acupuncturist.
NOTICE OF PERSONAL CHIROPRACTOR OR PERSONAL ACUPUNCTURIST
If your employer or your employer's insurer does not have a Medical Provider Network, you may be able to change your treating physician to your personal chiropractor or acupuncturist following a work-related injury or illness. In order to be eligible to make this change, you must give your employer the name and business address of a personal chiropractor or acupuncturist in writing prior to the injury or illness. Your claims administrator generally has the right to select your treating physician within the first 30 days after your employer knows of your injury or illness. After your claims administrator has initiated your treatment with another doctor during this period, you may then, upon request, have your treatment transferred to your personal chiropractor or acupuncturist.
You may use this form to notify your employer of your personal chiropractor or acupuncturist.
Your Chiropractor or Acupuncturist's Information:
______________________________________________
(name of chiropractor or acupuncturist)
______________________________________________
(street address, city, state, zip code)
______________________________________________
(telephone number)
Employee Name (please print):
______________________________________________
Employee's Address:
______________________________________________
Employee's Signature _______________ Date: ___
Title 8, California Code of Regulations, section 9783.1. (DWC Form 9783.1- Effective date March 2006)
Note: Authority cited: Sections 133, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600 and 4601, Labor Code.
s 9784. Duties of the Employer.
Note: Authority cited: Sections 124, 127, 133, 138.2, 138.3, 138.4, 139, 139.5, 139.6, 4600, 4601, 4602, 4603, 4603.2, 4603.5, 5307.3, 5450, 5451, 5452, 5453, 5454, and 5455, Labor Code. Reference: Chapters 442, 709, and 1172, Statutes of 1977; Chapter 1017, Statutes of 1976.
s 9785. Reporting Duties of the Primary Treating Physician.
(a) For the purposes of this section, the following definitions apply:
(1) The "primary treating physician" is the physician who is primarily responsible for managing the care of an employee, and who has examined the employee at least once for the purpose of rendering or prescribing treatment and has monitored the effect of the treatment thereafter. The primary treating physician is the physician selected by the employer, the employee pursuant to Article 2 (commencing with section 4600) of Chapter 2 of Part 2 of Division 4 of the Labor Code, or under the contract or procedures applicable to a Health Care Organization certified under section 4600.5 of the Labor Code, or in accordance with the physician selection procedures contained in the medical provider network pursuant to Labor Code section 4616.
(2) A "secondary physician" is any physician other than the primary treating physician who examines or provides treatment to the employee, but is not primarily responsible for continuing management of the care of the employee.
(3) "Claims administrator" is a self-administered insurer providing security for the payment of compensation required by Divisions 4 and 4.5 of the Labor Code, a self-administered self-insured employer, or a third-party administrator for a self-insured employer, insurer, legally uninsured employer, or joint powers authority.
(4) "Medical determination" means, for the purpose of this section, a decision made by the primary treating physician regarding any and all medical issues necessary to determine the employee's eligibility for compensation. Such issues include but are not limited to the scope and extent of an employee's continuing medical treatment, the decision whether to release the employee from care, the point in time at which the employee has reached permanent and stationary status, and the necessity for future medical treatment.
(5) "Released from care" means a determination by the primary treating physician that the employee's condition has reached a permanent and stationary status with no need for continuing or future medical treatment.
(6) "Continuing medical treatment" is occurring or presently planned treatment that is reasonably required to cure or relieve the employee from the effects of the injury.
(7) "Future medical treatment" is treatment which is anticipated at some time in the future and is reasonably required to cure or relieve the employee from the effects of the injury.
(8) "Permanent and stationary status" is the point when the employee has reached maximal medical improvement, meaning his or her condition is well stabilized, and unlikely to change substantially in the next year with or without medical treatment.
(b)(1) An employee shall have no more than one primary treating physician at a time.
(2) An employee may designate a new primary treating physician of his or her choice pursuant to Labor Code ss 4600 or 4600.3 provided the primary treating physician has determined that there is a need for:
(A) continuing medical treatment; or
(B) future medical treatment. The employee may designate a new primary treating physician to render future medical treatment either prior to or at the time such treatment becomes necessary.
(3) If the employee disputes a medical determination made by the primary treating physician, including a determination that the employee should be released from care, or if the employee objects to a decision made pursuant to Labor Code section 4610 to modify, delay, or deny a treatment recommendation, the dispute shall be resolved under the applicable procedures set forth at Labor Code sections 4061 and 4062. No other primary treating physician shall be designated by the employee unless and until the dispute is resolved.
(4) If the claims administrator disputes a medical determination made by the primary treating physician, the dispute shall be resolved under the applicable procedures set forth at Labor Code sections 4610, 4061 and 4062.
(c) The primary treating physician, or a physician designated by the primary treating physician, shall make reports to the claims administrator as required in this section. A primary treating physician has fulfilled his or her reporting duties under this section by sending one copy of a required report to the claims administrator. A claims administrator may designate any person or entity to be the recipient of its copy of the required report.
(d) The primary treating physician shall render opinions on all medical issues necessary to determine the employee's eligibility for compensation in the manner prescribed in subdivisions (e), (f) and (g) of this section. The primary treating physician may transmit reports to the claims administrator by mail or FAX or by any other means satisfactory to the claims administrator, including electronic transmission.
(e)(1) Within 5 working days following initial examination, a primary treating physician shall submit a written report to the claims administrator on the form entitled "Doctor's First Report of Occupational Injury or Illness," Form DLSR 5021. Emergency and urgent care physicians shall also submit a Form DLSR 5021 to the claims administrator following the initial visit to the treatment facility. On line 24 of the Doctor's First Report, or on the reverse side of the form, the physician shall (A) list methods, frequency, and duration of planned treatment(s), (B) specify planned consultations or referrals, surgery or hospitalization and (C) specify the type, frequency and duration of planned physical medicine services (e.g., physical therapy, manipulation, acupuncture).
(2) Each new primary treating physician shall submit a Form DLSR 5021 following the initial examination in accordance with subdivision (e)(1).
(3) Secondary physicians, physical therapists, and other health care providers to whom the employee is referred shall report to the primary treating physician in the manner required by the primary treating physician.
(4) The primary treating physician shall be responsible for obtaining all of the reports of secondary physicians and shall, unless good cause is shown, within 20 days of receipt of each report incorporate, or comment upon, the findings and opinions of the other physicians in the primary treating physician's report and submit all of the reports to the claims administrator.
(f) A primary treating physician shall, unless good cause is shown, within 20 days report to the claims administrator when any one or more of the following occurs:
(1) The employee's condition undergoes a previously unexpected significant change;
(2) There is any significant change in the treatment plan reported, including, but not limited to, (A) an extension of duration or frequency of treatment, (B) a new need for hospitalization or surgery, (C) a new need for referral to or consultation by another physician, (D) a change in methods of treatment or in required physical medicine services, or (E) a need for rental or purchase of durable medical equipment or orthotic devices;
(3) The employee's condition permits return to modified or regular work;
(4) The employee's condition requires him or her to leave work, or requires changes in work restrictions or modifications;
(5) The employee is released from care;
(6) The primary treating physician concludes that the employee's permanent disability precludes, or is likely to preclude, the employee from engaging in the employee's usual occupation or the occupation in which the employee was engaged at the time of the injury, as required pursuant to Labor Code Section 4636(b);
(7) The claims administrator reasonably requests appropriate additional information that is necessary to administer the claim. "Necessary" information is that which directly affects the provision of compensation benefits as defined in Labor Code Section 3207.
(8) When continuing medical treatment is provided, a progress report shall be made no later than forty-five days from the last report of any type under this section even if no event described in paragraphs (1) to (7) has occurred. If an examination has occurred, the report shall be signed and transmitted within 20 days of the examination.
Except for a response to a request for information made pursuant to subdivision (f)(7), reports required under this subdivision shall be submitted on the "Primary Treating Physician's Progress Report" form (Form PR-2) contained in Section 9785.2, or in the form of a narrative report. If a narrative report is used, it must be entitled "Primary Treating Physician's Progress Report" in bold-faced type, must indicate clearly the reason the report is being submitted, and must contain the same information using the same subject headings in the same order as Form PR-2. A response to a request for information made pursuant to subdivision (f)(7) may be made in letter format. A narrative report and a letter format response to a request for information must contain the same declaration under penalty of perjury that is set forth in the Form PR-2: "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 s 139.3."
By mutual agreement between the physician and the claims administrator, the physician may make reports in any manner and form.
(g) When the primary treating physician determines that the employee's condition is permanent and stationary, the physician shall, unless good cause is shown, report within 20 days from the date of examination any findings concerning the existence and extent of permanent impairment and limitations and any need for continuing and/or future medical care resulting from the injury. The information may be submitted on the "Primary Treating Physician's Permanent and Stationary Report" form (DWC Form PR-3 or DWC Form PR-4) contained in section 9785.3 or section 9785.4, or in such other manner which provides all the information required by Title 8, California Code of Regulations, section 10606. For permanent disability evaluation performed pursuant to the permanent disability evaluation schedule adopted on or after January 1, 2005, the primary treating physician's reports concerning the existence and extent of permanent impairment shall describe the impairment in accordance with the AMA Guides to the Evaluation on Permanent Impairment, 5th Edition (DWC Form PR-4). Qualified Medical Evaluators and Agreed Medical Evaluators may not use DWC Form PR-3 or DWC Form PR-4 to report medical-legal evaluations.
(h) Any controversies concerning this section shall be resolved pursuant to Labor Code Section 4603 or 4604, whichever is appropriate.
(i) Claims administrators shall reimburse primary treating physicians for their reports submitted pursuant to this section as required by the Official Medical Fee Schedule.
Note: Authority cited: Sections 133, 4603.5 and 5307.3, Labor Code. Reference: Sections 4061, 4061.5, 4062, 4600, 4600.3, 4603.2, 4636, 4660, 4662, 4663 and 4664, Labor Code.
s 9785.2. Form PR-2 "Primary Treating Physician's Progress Report."
Note: Authority cited: Sections 133, 4603.5 and 5307.3, Labor Code. Reference: Sections 4061.5, 4600, 4603.2, 4610, 4636, 4660, 4662, 4663 and 4664, Labor Code.
s 9785.3. Form PR-3 "Primary Treating Physician's Permanent and Stationary Report."
Note: Authority cited: Sections 133, 4603.5 and 5307.3, Labor Code. Reference: Sections 4061.5, 4600, 4603.2, 4636, 4660, 4662, 4663 and 4664, Labor Code.
s 9785.4. Form PR-4 "Primary Treating Physician's Permanent and Stationary Report."
STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION PRIMARY TREATING
PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-4)
Note: Authority cited: Sections 133 and 5307.3, Labor Code. Reference: Sections 4600, 4061.5, 4603.2, 4636, 4660, 4662, 4663 and 4664, Labor Code.
s 9785.5. Primary Treating Physician.
Note: Authority cited: Sections 133, 4061.5, 4603.5 and 5307.3, Labor Code. Reference: Sections 139 and 4061.5, Labor Code.
s 9786. Petition for Change of Primary Treating Physician.
(a) A claims administrator desiring a change of primary treating physician pursuant to Labor Code Section 4603 shall file with the Administrative Director a petition, verified under penalty of perjury, on the "Petition for Change of Primary Treating Physician" form (DWC-Form 280 (Part A)) contained in Section 9786.1.
The petition shall be accompanied by supportive documentary evidence relevant to the specific allegations raised. A proof of service by mail declaration shall be attached to the petition indicating that (1) the completed petition (Part A), (2) the supportive documentary evidence and (3) a blank copy of the "Response to Petition for Change of Primary Treating Physician", (DWC-Form 280 (Part B)), were served on the employee or, the employee's attorney, and the employee's current primary treating physician.
(b) Good cause to grant the petition shall be clearly shown by verified statement of facts, and, where appropriate, supportive documentary evidence. Good cause includes, but is not limited to any of the following:
(1) The primary treating physician has failed to comply with Section 9785, subdivisions (e), (f)(1-7), or (g) by not timely submitting a required report or submitting a report which is inadequate due to material omissions or deficiencies;
(2) The primary treating physician has failed to comply with subdivision (f)(8) of Section 9785 by failing to submit timely or complete progress reports on two or more occasions within the 12-month period immediately preceding the filing of the petition;
(3) A clear showing that the current treatment is not consistent with the treatment plan submitted pursuant to Section 9785, subdivisions (e) or (f);
(4) A clear showing that the primary treating physician or facility is not within a reasonable geographic area as determined by Section 9780(e).
(5) A clear showing that the primary treating physician has a possible conflict of interest, including but not limited to a familial, financial or employment relationship with the employee, which has a significant potential for interfering with the physician's ability to engage in objective and impartial medical decision making.
(c)(1) Where good cause is based on inadequate reporting under subdivisions (b)(1) or (b)(2), the petition must show, by documentation and verified statement, that the claims administrator notified the primary treating physician or facility in writing of the complete requirements of Section 9785 prior to the physician's failure to properly report.
(2) Good cause shall not include a showing that current treatment is inappropriate or that there is no present need for medical treatment to cure or relieve from the effects of the injury or illness. The claims administrator's contention that current treatment is inappropriate, or that the employee is no longer in need of medical treatment to cure or relieve from the effects of the injury or illness should be directed to the Workers' Compensation Appeals Board, not the Administrative Director, in support of a Petition for Change of Primary Treating Physician.
(3) Where an allegation of good cause is based upon failure to timely issue the "Doctor's First Report of Occupational Injury or Illness," Form DLSR 5021, within 5 working days of the initial examination pursuant to Section 9785(e)(1) or (e)(2), the petition setting forth such allegation shall be filed within 90 days of the initial examination.
(4) The failure to verify a letter response to a request for information made pursuant to Section 9785(f)(7), failure to verify a narrative report submitted pursuant to Section 9785(f)(8), or failure of the narrative report to conform to the format requirements of Section 9785(f)(8) shall not constitute good cause to grant the petition unless the claims administrator submits documentation showing that the physician was notified of the deficiency in the verification or reporting format and allowed a reasonable time to correct the deficiency.
(d) The employee, his or her attorney, and/or the primary treating physician may file with the Administrative Director a response to said petition, provided the response is verified under penalty of perjury and is filed and served on the claims administrator and all other parties no later than 20 days after service of the petition. The response may be accompanied by supportive documentary evidence relevant to the specific allegations raised in the petition. The response may be filed using the "Response to Petition for Change of Primary Treating Physician" form (DWC-Form 280 (Part B)) contained in Section 9786.1. Where the petition was served by mail, the time for filing a response shall be extended pursuant to the provisions of Code of Civil Procedure Section 1013. Unless good cause is shown, no other document will be considered by the Administrative Director except for the petition, the response, and supportive documentary evidence.
(e) The Administrative Director shall, within 45 days of the receipt of the petition, either:
(1) Dismiss the petition, without prejudice, for failure to meet the procedural requirements of this Section;
(2) Deny the petition pursuant to a finding that there is no good cause to require the employee to select a primary treating physician from the panel of physicians provided in the petition;
(3) Grant the petition and issue an order requiring the employee to select a physician from the panel of physicians provided in the petition, pursuant to a finding that good cause exists therefor;
(4) Refer the matter to the Workers' Compensation Appeals Board for hearing and determination by a Workers' Compensation Administrative Law Judge of such factual determinations as may be requested by the Administrative Director; or
(5) Issue a Notice of Intention to Grant the petition and an order requiring the submission of additional documents or information.
(f) The claims administrator's liability to pay for medical treatment by the primary treating physician shall continue until an order of the Administrative Director issues granting the petition.
(g) The Administrative Director may extend the time specified in Subsection (e) within which to act upon the claims administrator's petition for a period of 30 days and may order a party to submit additional documents or information.
Note: Authority cited: Sections 133, 139.5, 4603, 4603.2, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600, 4603 and 4603.2, Labor Code.
s 9786.1. Petition for Change of Primary Treating Physician; Response to Petition for Change of Primary Treating Physician (DWC Form 280 (Parts A and B)).
STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF WORKERS' COMPENSATION
________________________________________________________________
WCAB Case Nos. (If any):________________________________________
EMPLOYEE: ______________________________________________________
EMPLOYEE'S
ADDRESS ________________________________________________________
EMPLOYEE'S ATTORNEY: ___________________________________________ (continued)