Can an electronic signature be used?

Yes. Electronic signatures are legally valid under the federal ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and record retention requirements are met.

What if the employee signs with initials?

Initials alone may be insufficient unless the form explicitly permits them. A full dated signature or compliant eSignature is recommended to avoid challenges to authenticity.

Is a notary ever required?

Most provider-change forms do not require notarization, but state or plan rules may require it for certain authorizations; check state notary rules or plan documents before assuming none is needed.

How long does processing take?

Processing timelines depend on employer and insurer workflows; routine acknowledgements often occur within 3–5 business days, while authorization decisions may take longer.

What records must be kept?

Retain signed forms per applicable standards, including IRS record rules (IRC §6501(a)) and HIPAA retention requirements (45 CFR §164.530(j)) where PHI is involved.

How to correct an error on a submitted form?

Submit a corrected form with a clear notation that it supersedes prior versions and include both the original and corrected submission in the administrative record to preserve auditability.

Electronic Signature
Templates
Other
Employee's Choice or Change of Doctor Form

Employee's Choice or Change of Doctor Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

EMPLOYEE'S CHOICE OR CHANGE OF DOCTOR FORM

NOTICE TO EMPLOYER:

GIVE THIS FORM TO THE INJURED WORKER AS SOON AS POSSIBLE AFTER EACH INJURY

PART A: NOTICE REGARDING CHOICE OR CHANGE OF DOCTOR

Under the Nebraska workers' compensation laws, you may have the right to choose a doctor to treat you for your work-related injury. You may choose a doctor who has treated you or an immediate family member before this injury happened. Immediate family members are your spouse, children, parents, stepchildren and stepparents. The doctor you choose must have records to show that past treatment was provided. Your employer may ask the person who was treated to give permission so the doctor can verify past treatment.

If you want to choose your doctor, you must tell your employer the name of the doctor you choose. Do this as soon as possible after your employer gives you this notice and before getting any treatment unless it is emergency medical treatment. Once you tell your employer the name of the doctor, you may not change your choice unless your employer agrees or the Nebraska Workers' Compensation Court orders a change.

If you do not choose your doctor, your employer has the right to choose the doctor to treat you. The employer may also choose the doctor to treat you if you or your family member does not give permission so your employer can verify past treatment by the doctor you chose.

You may choose a doctor if your claim is denied. You may also choose the doctor to do major surgery or for an amputation.

You may use Part B (below) to tell your employer the name of the doctor you choose.

My employer has informed me of the above information regarding choice or change of doctor.

[PRINT NAME OF EMPLOYEE]

[SIGNATURE OF EMPLOYEE]

[DATE]

PART B: CHOICE OF DOCTOR

I choose the following doctor to treat me for this work-related injury. I certify that this doctor has treated me or an immediate family member before the work-related injury.

I do not have or I do not wish to choose a doctor who has treated me or an immediate family member.

[DOCTOR'S NAME]

[SIGNATURE OF EMPLOYEE]

[DOCTOR'S ADDRESS]

[DATE]

PART C: USE TO CHANGE THE CHOICE MADE IN PART B, ABOVE

I wish to change my choice of doctor or I wish to choose a doctor to treat me for my work-related injury. I certify the doctor named below has treated me or an immediate family member before this work-related injury. I understand that I cannot make this change unless my employer agrees or unless the Nebraska Workers' Compensation Court orders a change.

[DOCTOR'S NAME]

[SIGNATURE OF EMPLOYEE & DATE OF SIGNATURE]

[DOCTOR'S ADDRESS]

[SIGNATURE OF EMPLOYER & DATE OF SIGNATURE]

NWCC Form 50 - Revised 03/2013

What the Employee's Choice or Change of Doctor Form Is

The Employee's Choice or Change of Doctor Form documents an employee's designation of a treating physician or request to change providers, typically within an employer, workers' compensation, or insurance-managed care context. It captures identifying information, the chosen practitioner's details, and the effective date of the requested change. Employers and insurers use the form to update medical authorizations, route appointments, and record consent. The form may be required to trigger benefits, direct care assignments, or administrative routing for claims and must be completed accurately to avoid delays in treatment or coverage disputes.

Why Completing This Form Matters

Accurate completion authorizes provider assignment, preserves continuity of care, and creates a clear administrative record for benefits and claims. It reduces processing delays and helps ensure medical bills route to the correct payer.

Who Typically Completes and Reviews the Form

The form is completed by employees seeking to select or change their treating physician and reviewed by HR, claims administrators, or insurer case managers before approval.

Employees seeking initial treatment or a provider change for workplace or insured injuries or conditions.
HR professionals and benefits administrators who record provider changes and notify payroll or insurance.
Claims adjusters and nurse case managers who verify medical eligibility and authorize appointments.

Timely review and clear recordkeeping by these stakeholders prevents billing errors and supports appropriate medical oversight.

Primary Roles Involved

HR Manager

HR Managers receive completed forms, confirm employment details, and coordinate with benefits or claims teams to ensure provider changes comply with plan rules. They log the change and notify payroll or administrative systems as needed for benefits administration.

Employee

Employees use the form to state their preferred treating physician or request a change after initial care. Accurate contact and identifier details ensure appointments and bills are routed correctly and that benefits are not delayed or denied.

Essential Parts of a Professional Form

A well-designed Employee's Choice or Change of Doctor Form balances clear data fields, legal acknowledgements, and processing instructions so employers and payers can act quickly and maintain compliance.

Employee Details

Full legal name, employee ID, contact information, job title and department to match HR and claims records for identification and routing.

Provider Selection

Chosen provider name, clinic or hospital, address, phone, and provider license or NPI if available to avoid misrouting or duplicate records.

Effective Date

Date the selection or change takes effect; determines appointment scheduling and which provider is responsible for care from that date forward.

Reason for Change

Brief explanation (transfer, dissatisfaction, specialist referral) to aid administrative review and expedite approvals.

Authorizations

Employee signature and dated consent, plus any employer/insurer acknowledgement area for acceptance or denial with reason code.

Processing Notes

Internal use fields for claim number, reviewer initials, and follow-up steps to document the administrative workflow and decision.

Step-by-Step: Completing and Submitting the Form

Follow these steps in order to complete and route the form accurately for employer or insurer processing.

01

Fill Fields: Complete all required fields accurately before signing.
02

Sign: Provide dated signature or valid eSignature per platform instructions.
03

Submit: Send to the designated HR or claims email or upload to the claims portal.
04

Track: Retain a copy and monitor confirmation from the reviewer.

Digital Workflow Configuration Options

Configure an online workflow to capture consent, authenticate signers, and route completed forms to HR and claims teams.

Field	Configuration
Signature Field	Require eSignature with timestamp
Authentication	Email link plus optional SMS code
Routing	Auto-send to HR and claims inboxes
Notifications	Email confirmations to employee and reviewer

Typical Electronic Submission Flow

A standard eSubmission reduces manual handoffs and creates an audit trail for each action in the process.

Upload: Sender uploads form to platform
Place Fields: Add signature, date, and required inputs
Send Link: Employee receives secure signing link
Complete: Signed form is returned and archived

Platform and Integration Requirements

Ensure the chosen platform supports required authentication, audit trails, and integrations with HR or claims systems.

Authentication: Email and optional SMS verification
Integrations: Connects to HRIS or claims systems
File Formats: Accepts PDF and DOCX uploads

Integrations with HRIS, claims platforms, and cloud storage minimize manual entry and help preserve records for audits and appeals.

Typical Timelines and Processing Expectations

Timelines vary by employer and insurer; plan rules determine when a change becomes effective and when appointments can be scheduled.

Employee Submission Window:

Submit as soon as possible after the decision to change providers.

Employer Acknowledgement:

Many administrators acknowledge receipt within 3–5 business days.

Claims Processing:

Coverage decisions or authorization may take up to 10 business days.

Appointment Scheduling:

Scheduling depends on provider availability and authorization status.

Appeals Timeline:

Follow insurer or plan appeal deadlines for denials; check plan documents.

Key Administrative Milestones

Track these sequential milestones from request to confirmed treatment to ensure timely care and accurate records.

01

Request Submitted

Employee files form initiating the change request.

02

Acknowledgement Issued

HR or claims team records and confirms receipt.

03

Authorization Decision

Insurer or reviewer approves or denies the change.

04

Provider Notification

New provider receives appointment and billing details.

Common Mistakes That Delay Processing

Leaving required sections blank, such as employee ID or effective date, which forces manual follow-up and delays approvals.
Using an informal provider name without address or NPI, resulting in misrouted appointments or duplicate provider records.
Submitting unsigned forms or using initials where a full signature or dated eSignature is required under policy.
Failing to send the form to the correct HR or claims contact, which can cause the request to be overlooked or rejected.

Risks of Incorrect or Late Forms

Denied Coverage: Possible

Delayed Care: Likely

Billing Errors: Possible

Appeals Needed: May be required

Record Discrepancies: Creates audit issues

Legal Exposure: Limited but possible

How This Form Compares to Similar Documents

Compare the Employee's Choice or Change of Doctor Form to alternate forms used for provider designation or referral.

Criteria	Employee Choice Form	Referral Authorization
Required fields	full id info	provider and diagnosis
Notarization		rarely
Electronic signing	allowed	allowed
Typical use	provider selection	specialist referral

eSignature Vendor Pricing and Feature Comparison

Basic pricing and feature availability for common eSignature vendors. signNow is listed first as the reference column; features and prices vary by plan and billing terms.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	Yes, 7-day free trial	Varies	Varies	Varies	Varies
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies	Varies	Varies

Frequently Asked Questions

Answers to common questions about signing, validity, and practical next steps for the Employee's Choice or Change of Doctor Form.

Need help? Contact support

Can an electronic signature be used?
Yes. Electronic signatures are legally valid under the federal ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and record retention requirements are met.
What if the employee signs with initials?
Initials alone may be insufficient unless the form explicitly permits them. A full dated signature or compliant eSignature is recommended to avoid challenges to authenticity.
Is a notary ever required?
Most provider-change forms do not require notarization, but state or plan rules may require it for certain authorizations; check state notary rules or plan documents before assuming none is needed.
How long does processing take?
Processing timelines depend on employer and insurer workflows; routine acknowledgements often occur within 3–5 business days, while authorization decisions may take longer.
What records must be kept?
Retain signed forms per applicable standards, including IRS record rules (IRC §6501(a)) and HIPAA retention requirements (45 CFR §164.530(j)) where PHI is involved.
How to correct an error on a submitted form?
Submit a corrected form with a clear notation that it supersedes prior versions and include both the original and corrected submission in the administrative record to preserve auditability.

Explore Templates

Colorado School of Mines Recreation Waiver Waiver Form Sharonamerican Cadre Karate Waiver and Release by Parent of Minor from Liability for Aerobic Liability Waiver Form Waiver and Release of Liability Tolling Agreement

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now