§ 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

ADMINISTRATIVE DIRECTOR

Post Office Box 420603

San Francisco, CA 94142

PETITION FOR CHANGE OF PRIMARY TREATING PHYSICIAN

(LABOR CODE s 4603 & TITLE 8, CALIFORNIA CODE OF REGULATIONS, s 9786)

________________________________________________________________

(Print or Type Names and Addresses)

WCAB Case Nos. (If any):________________________________________

EMPLOYEE: ______________________________________________________

EMPLOYEE'S

ADDRESS ________________________________________________________

EMPLOYEE'S ATTORNEY: ___________________________________________

EMPLOYER: ______________________________________________________

EMPLOYER'S ADDRESS:_____________________________________________

CLAIMS ADMINISTRATOR: __________________________________________

CLAIMS ADMINISTRATOR'S ADDRESS _________________________________

CLAIMS ADMINISTRATOR'S CLAIM NUMBER(S): ________________________

NAME OF PRIMARY TREATING PHYSICIAN _____________________________

PRIMARY TREATING PHYSICIAN'S ADDRESS: __________________________

PHYSICIAN PANEL: List below the NAMES, ADDRESSES AND MEDICAL SPECIALTIES (e.g.-orthopedics, cardiology, etc.) of a panel of FIVE (5) physicians (to include one chiropractor if the employee is being treated by a chiropractor) available to provided treatment of the employee's injury in the event this petition is granted.

1. _____________________________________________________________

2. _____________________________________________________________

3. _____________________________________________________________

4. _____________________________________________________________

5. _____________________________________________________________

Part A.

Petitioner states that the following constitutes good cause for issuance of an Order Granting Petition For Change Of Primary Treating Physican: (Additional sheets may be attached if necessary)

NOTE: Attach to this Petition any supportive evidence (medical reports, declarations, etc.) that establishes good cause for the Petition to be granted. (See Title 8, California Code of Regulations, Section 9786)

VERIFICATION

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

EXECUTED AT ___________________. CALIFORNIA ON _________________

(City) (Date)

BY:_____________________________//______________________________

Original Signature of Petitioner's // Name of Petitioner's

Representative Preparing // Representative Preparing the

the Petition Petition (Print or type)

________________________________________________________________

(Address of Petitioner)

________________________________________________________________

YOU MUST ATTACH A PROOF OF SERVICE BY MAIL DECLARATION INDICATING THAT: (1) PART a (PETITION FOR CHANGE OF PRIMARY TREATING PHYSICIAN) AND PART B (RESPONSE TO PETITION FOR CHANGE OF PRIMARY TREATING PHYSICIAN) OF THIS FORM AND (2) ALL SUPPORTIVE EVIDENCE WERE MAILED TO THE EMPLOYEE OR THE EMPLOYEE'S ATTORNEY, AND THE PRIMARY TREATING PHYSICIAN.

________________________________________________________________

Notice to Employee/Employee's Attorney and Primary Treating Physician:

Pursuant to Title 8, California Code of Regulations, Section 9786(d), you may file with the Administrative Director a RESPONSE to this petition within 20 days from the date the petition was served on you. Your Response must be submitted using the Response to Petition for Change of Treating Physician form which is contained in Part B on Pages 3 and 4 of this form. You may attach additional sheets as needed to the Response form.

________________________________________________________________

RESPONSE TO PETITION FOR CHANGE OF PRIMARY TREATING PHYSICIAN

(LABOR CODE s 4603 & TITLE 8, CALIFORNIA CODE OF REGULATIONS, s 9786(d)

________________________________________________________________

(Print or type names and addresses)

WCAB Case Nos. (If any):________________________________________

EMPLOYEE: ______________________________________________________

EMPLOYEE'S ATTORNEY: ___________________________________________

EMPLOYER: ______________________________________________________

CLAIMS ADMINISTRATOR: __________________________________________

CLAIMS ADMINISTRATOR'S CLAIM NUMBER(S): ________________________

NAME OF PRIMARY TREATING PHYSICIAN _____________________________

________________________________________________________________

The petition filed by or on behalf of the Claims Administrator does not establish good cause for the issuance of an Order Granting Petition For Change Of Primary Treating Physician based on the following: (additional sheets may be attached if necessary)

IMPORTANT: Attach to this Response any supportive documentary evidence (medical reports, affidavit and declaration, etc.) which established that there is not good cause for the Administrative Director to grant the Petition for Change of Primary Physician. (See Title 8, California Code of Regulations, s 9786)

VERIFICATION

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

EXECUTED AT _______________________, CALIFORNIA ON _____________

(City) (Date)

BY: ________________________________//__________________________

Original Signature of Person // Name of Person Preparing

Preparing the Response // the Response (Print or type)

Address: _______________________________________________________

NOTICE TO EMPLOYEE/EMPLOYEE'S ATTORNEY: THE PROOF OF SERVICE BY MAIL DECLARATION BELOW MUST BE COMPLETED INDICATING A COPY OF THIS RESPONSE HAS BEEN MAILED TO THE CLAIMS ADMINISTRATOR OR ITS ATTORNEY, AND THE PRIMARY TREATING PHYSICIAN.

NOTICE TO PRIMARY TREATING PHYSICIAN: THE PROOF OF SERVICE BY MAIL DECLARATION BELOW MUST BE COMPLETED INDICATING A COPY OF THIS RESPONSE HAS BEEN MAILED TO THE CLAIMS ADMINISTRATOR OR ITS ATTORNEY, AND THE EMPLOYEE OR THE EMPLOYEE'S ATTORNEY.

PROOF OF SERVICE BY MAIL$u

On _____________I served a copy of this Response to Petition forChange of Treating Physician on

(date)

______________________ at __________________________________ and

(Claims Administrator or its Attorney) (address)

______________________ at __________________________________ and

(Primary Treating Physician (address)

or Employee/Employee's/

Attorney)

placing a true copy enclosed is a sealed envelope, addressed as indicated above and with postage fully prepaid, in the U.S. Mail at ______________, California. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

_______________________________//_______________________________

Original Signature of Declarant//Name of Declarant (Print or Type)

PART B

4

DWC Form 280 (Part B)(1/01)

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HISTORY

1. New section (DWC form 280) filed 12-22-2000; operative 1-1-2001 pursuant to Government Code section 11343.4(d) (Register 2000, No. 51).

Note

Note: Authority cited: Sections 133, 139.5, 4603.2, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600, 4603 and 4603.2, Labor Code.