Change Treating Doctor Form
Injured employees who want to change treating doctors must submit this form to their adjuster.
Within the first 60 days of treatment, injured employees are allowed one change of treating doctor to another within the Political Subdivision Workers’ Compensation Alliance panel. Employees must complete this form and send it to their adjuster for approval before seeing a new treating doctor.
You May Also Like…
View All Related ResourcesBona Fide Offer of Employment Template
When the doctor clears your injured employee to return to work, use this template to issue a bona fide offer of employment that meets state requirements.
Employee Acknowledgement of Alliance Direct Contracting Program
Employees must sign this form acknowledging they understand how to receive health care in the Political Subdivision Workers’ Compensation Alliance. Available in English and Spanish.
Employee Incident Investigation Worksheet
Uncover and correct the root causes of workplace accidents to reduce the risk of them happening again.