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Change Treating Doctor Form

Injured employees who want to change treating doctors must submit this form to their adjuster.

Form

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Change Treating Doctor Form

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.

WC_Alliance-Treating-Doctor-Change-Request-Form (1).pdf

PDF 219 KB

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Template

Bona 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.

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Form

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.

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