Employee's Designation of Personal Chiropractor (California Labor Code section 4601)
The California Worker's Compensation Laws make it easy for you to designate our office as your "Personal Chiropractor" for the treatment of a work related back injury. Once you designate this office you no longer have to go to the employer's doctor for a back injury. One catch is that you have had to be a prior patient of Dr. Sabato.
Most physicians are quite competent at emergency medicine. However, with soft tissue and muscle-skeletal back injuries chiropractors have more experience. Musculo-Skeletal and Soft Tissue Injuries Include The Following: Neck, mid and low back sprain/strain as well as Carpal Tunnel Syndrome.
Pre- Injury Pre-Employment Exam
As a service to our existing patients, their working family members and friends, this office is willing to perform a pre-injury or pre-employment exam at no charge. What will this do?
This will allow us to have on file a record of your medical history relating to the above musculo-skeletal and soft tissue conditions.
This will then enable you to designate this office as your "Personal Chiropractor".
Recent Change of Employer
If you have recently changed employers, you need an updated "Personal Chiropractor" designation form signed and on file with your new employer as well in your treatment file at this office.
The employer and personnel department MUST honor this new request. What the form in effect says is, "I have my own chiropractor whom I want to treat me in the event I injure my back at work. He, my chiropractor, is the custodian of my medial records".
If you have any questions regarding the designation of a "Personal Chiropractor" under the California Workers' Compensation system, feel free to contact me.
Instructions to Employee: You will have to print out THREE (3) NOTICE OF PERSONAL CHIROPRACTOR (PDF) form at the bottom of this page.
The ORIGINAL form is for your employer HR Department
The SECOND copy is for your records
The THIRD copy is to give to this office to be kept in your treatment records.
Make sure that the employer or their representative places this form in your personnel file. Go back after one week and ask to see your personnel file to check if this form is in it. If it is not, insist! It is your right under Labor Code to designate a "Personal Chiropractor".
You may choose your treating doctor in any of the following situations:
Employer leaves the decision up to you.
Employer refuses to authorize treatment.
Employer has contracted with two health care organizations to provide care to employees who are injured at work and you were not advised of your right to pre-designated your treating doctor in writing when hired, by the end of the first pay period, and at least one year after (LC3551).
Employer failed to post notice of your workers' compensation rights or advised you of your rights to pre-designate your doctor or "Personal Chiropractor" when you were hired or by the end of your first pay period.
After informing your employer about your injury, your employer did not provide you with a claim form and information about workers' compensation benefits.
You can go to the emergency room of your choice if you require emergency medical care.
Employer Instructions: Place the sign copy of this form into the employees' file. In case of a back injury the employee has designate his/her choice of care. There is no need to go to the company doctor and be treated for the 30-day elimination period.
Forms that need to be printed out are the following. Double click on each of the following items to open them, then print. Afterward you can emil them back to me at: email@example.com ; or fax at: 916-631-1979; or mail them back to 2377 Gold Meadow Way, Suite 100, Gold River, CA 95670-4444.
KEEP ONE COPY FOR YOUR RECORDS
MAKE SURE YOUR "PERSONAL CHIROPRACTOR"HAS A COPY IN YOUR FILE