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 California Code of Regulations (Last Updated: August 6, 2014)
 Title 8. Industrial Relations
 Division 1. Department of Industrial Relations
 Chapter 4.5. Division of Workers' Compensation
 Subchapter 1. Administrative Director -Administrative Rules
 Article 3.6. Independent Medical Review

  § 9768.5. Physician Contract Application Form.  

Latest version.
  • Image 1 within § 9768.5. Physician Contract Application Form.​
    Image 2 within § 9768.5. Physician Contract Application Form.​
    Image 3 within § 9768.5. Physician Contract Application Form.​
    Image 4 within § 9768.5. Physician Contract Application Form.​
    (Note to physicians: please use three letter specialty code when completing block 3 of application form)
    SPECIALTY CODES
    MAI Allergy and Immunology
    MAA Anesthesiology
    MRS Colon & Rectal Surgery
    MDE Dermatology
    MEM Emergency Medicine
    MFP Family Practice
    MPM General Preventive Medicine
    MOSU Hand - Orthopaedic Surgery, Plastic Surgery, General Surgery
    MMM Internal Medicine
    MMV Internal Medicine - Cardiovascular Disease
    MME Internal Medicine - Endocrinology Diabetes and Metabolism
    MMG Internal Medicine - Gastroenterology
    MMH Internal Medicine - Hematology
    MMI Internal Medicine - Infectious Disease
    MMO Internal Medicine - Medical Oncology
    MMN Internal Medicine - Nephrology
    MMP Internal Medicine - Pulmonary Disease
    MMR Internal Medicine - Rheumatology
    MPN Neurology
    MNS Neurological Surgery
    MNM Nuclear Medicine
    MOG Obstetrics and Gynecology
    MPO Occupational Medicine
    MOP Opthalmology
    MOSG Orthopaedic Surgery (General)
    MOSS Orthopaedic - Shoulder
    MOSK Orthopaedic - Knee
    MOSB Orthopaedic - Spine
    MOSF Orthopaedic - Foot and ankle
    MTO Otolaryngology
    MAP Pain Management - Psychiatry and Neurology, Physical Medicine and Rehabilitation, Anesthesiology
    MHA Pathology
    MEP Pediatrics
    MPR Physical Medicine & Rehabilitation
    MPS Plastic Surgery
    MPD Psychiatry
    MSY Surgery
    MSG Surgery - General Vascular
    MTS Thoracic Surgery
    MTO Toxicology - Preventive Medicine, Pediatrics, Emergency
    MUU Urology
    MRD Radiology
    POD Podiatry
    DWC Form 9768.5
    May 2007
HISTORY
1. New section filed 12-31-2004 as an emergency; operative 1-1-2005 (Register 2004, No. 53). A Certificate of Compliance must be transmitted to OAL by 5-2-2005 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 12-31-2004 order, including amendment of section, transmitted to OAL 4-29-2005 and filed 6-10-2005 (Register 2005, No. 23).
3. Change without regulatory effect amending form filed 10-18-2006 pursuant to section 100, title 1, California Code of Regulations (Register 2006, No. 42).
4. Change without regulatory effect amending form filed 5-21-2007 pursuant to section 100, title 1, California Code of Regulations (Register 2007, No. 21).

Note

Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Section 4616.4, Labor Code.Authority cited: Sections 133 and 4616, Labor Code. Reference: Section 4616.4, Labor Code.