It depends on whether you tell your employer in writing — before you are injured — the name
and address of your personal physician or a medical group. This is called “predesignating.” If
you predesignate, you may see your personal physician or the medical group right after you
are injured.

Can all workers predesignate?

No. You can predesignate only if, on your date of injury, you have health care coverage for
medical conditions that are unrelated to work. If you do not have this coverage, you do not
have a right to predesignate.

How to predesignate?

To predesignate your personal physician (if you are eligible to do so), you must notify
your employer in writing. You may prepare your own written statement, use optional
DWC Form 9783 is provided by the state Division of Workers’ Compensation, or use a
form provided by your employer. To download DWC Form 9783, go to:
(link to Forms). Note: If your employer or the insurer has a contract with a health care
organization (HCO), you must use a different form, discussed on the next page.

hurt on the job

Make sure to include the following information:
1. Name of your employer
2. A statement that if you are hurt on the job, you designate your personal physician to
provide medical care. Give the name, address, and phone number.
3. Your name
4. Your signature
5. Date

You can predesignate a doctor of medicine (MD) or doctor of osteopathy (DO) who
treated you in the past and has your medical records. The doctor must be a general
practitioner, internist, paediatrician, obstetrician-gynaecologist, or family practitioner who
is your primary care physician. You cannot predesignate your personal chiropractor or
acupuncturist, but if you give your employer the name of your personal chiropractor or
acupuncturist in writing before you are injured, you may switch to this chiropractor or
acupuncturist upon request, after you first see a doctor chosen by a claims administrator
(a person who handles workers’ compensation claims for your employer).

You may also predesignate a medical group if it meets the following criteria:
• Is composed of licensed doctors of medicine (MD) or doctors of osteopathy (DO)
• Offers and coordinates both primary care and care in other medical specialities
• Mostly treats medical conditions that are unrelated to work

You cannot predesignate unless the physician or medical group you predesignate agrees
in advance to treat you for job injuries and illnesses. You can document the agreement by
having the physician, an employee of the physician, or an employee of the medical group
sign the designation form, or by some other form of documentation. Include the
documentation when you give your employer the designation form or statement.