Fill and Sign the Petition for Change of Primary Treating Physician Dir Form

PART A \2 \2 \2 \2 \2                            DW\b Form 280 (Part A)\2 (1/01) 1 STATE OF \bALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF WORKERS\2’ \bOMPENSATION ADMINIST\bATIVE DI\bECT\OO\b Post Office Box 420603 San Francisco, CA 94142 PETITION FO\b CHANGE OF \OP\bIMA\bY T\bEATING PHYSICI\OAN (LABO\b CODE § 4603 & TITLE 8, CALIFO\bNIA CODE OF \bEGULATIONS, § 9786) ( Print or \bype Names and Addresses) W\bAB \base Nos. (If any): \2 \2 \2 \2 \2 \2 \2 \2 \2 \2 \2 EMPLOYEE : \2 \2 \2 \2 \2 \2 \2 EMPLOYEE’S ADDRESS: \2 \2 \2 \2 \2 \2 EMPLOYEE’S ATTORNEY : \2 \2 \2 \2 \2 \2 EMPLOYEE’S ATTORNEY’S\2 ADDRESS \2 \2 \2 \2 \2 \2 EMPLOYER : \2 \2 \2 \2 \2 \2 \2 EMPLOYER’S ADDRESS : \2 \2 \2 \2 \2 \2 \bLAIMS ADMINISTRATO\2R : \2 \2 \2 \2 \2 \2 \bLAIMS ADMINISTRATO\2R’S ADDRESS: \2 \2 \2 \2 \2 \2 \bLAIMS ADMINISTRATO\2R’S \bLAIM NUMBER(S) : \2 \2 \2 \2 \2 NAME OF PRIMARY TRE\2ATING PHYSI\bIAN \2 \2 \2 \2 \2 \2 \2 \2 \2 PRIMARY TREATING PHYS\2I\bIAN’S ADDRESS : \2 \2 \2 \2 \2 \2 PHYSI\bIAN PANEL: List below the NAMES, ADD\bESSES and MEDICAL SPECIALTIES (e.g.-orthopedics, cardiology, etc.) ofa panel of FIVE (5) physicians (to include one chiropractor if the employee is being treated by a chiropractor) available toprovide treatment of the employee’s injury in the event this petition is granted. 1. \2 \2 \2 \2 \2 \2 \2 \2 2. \2 \2 \2 \2 \2 \2 \2 \2 3. \2 \2 \2 \2 \2 \2 \2 \2 4. \2 \2 \2 \2 \2 \2 \2 \2 5. \2 \2 \2 \2 \2 \2 \2 \2 PART A \ \ DW\b Form 280 (Part A)\2 (1/01) 2 Petitioner states that the following constitutes good cause for issuance of an Order Gra\bti\bg Petitio\b For Cha\bge Of Primary Treati\bg Physicia\b: (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, \balifornia \bode of Regulations, Section 9786) VERIFI\bATION I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. EXE\bUTED AT \2 \2 \2 , \bALIFORNIA ON \2 \2 (\bity) (D ate) BY: \2 \2 \2 \2// ______________________________________ Original Signature of Petitioner’s Representativ e // Na me of Petitioner’s Representative Preparing the Petition Preparing the Petition \2 \2 \2 \2 (Print or type) \2 \2 \2 \2 \2 \2 \2 \2 \2 \2 \2 \2 (Address of Petitioner) \2 \2 \2 \2 \2 \2 \2 \2 \2 YOU MUST ATTACH A P\bOOF \OOF SE\bVICE BY MAIL DECLA\O\bATION INDICATING THA\OT: (1) PA\bT A (PETITION FO\b CHANGE OF P\bIMA\bY T\bEATING PHYSICIAN) AND PA\bT B (\bESPONSE TO PETITION FO\b CHANGE OF P\bIMA\bY T\bEATING PHYSICIAN) OF THIS FO\bM AND (2) ALL SUPPO\bTIVE EVIDENCE WE\bE MAILED TO THE EMPLOYEE O\b THE EMPLOYEE’S ATTO\bNEY, AND THE P\bIMA\bY T\bEATING PHYSICIAN. Notice to Employee/Employee’s Attorney and Primary \breating Physician: Pursuant to Title 8, Ca\Olifornia Code of \begulat\Oions, Section 9786(d), yo\Ou may file with the Administrative Directo\Or a \bESPONSE to this pe\Otition within 20 days\O from the date the peti\Otion was served on you. Your \be\Osponse must be submitted\O using the Response to Petition\a for Change of \breating P\ahysician form which is contain\Oed in Part B on Pages\O 3 and 4 of this form. Yo\Ou may attach additional \Osheets as needed to t\Ohe \besponse form . PART B 3 DWC Form 280 (Part B) (1/01) STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF WORKERS’ COMPENSATION ADMINISTRATIVE DIRECTOR Post Office Box 420603 San Francisco, CA 94142 RESPONSE TO PETITION FOR CHANGE OF PRIMARY TREATING PHYSICIAN (LABOR CODE § 4603 & TITLE 8, CALIFORNIA CODE OF REGULATIONS, § 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 : 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) PART B \r \r \r \r \r \r \bWC Form 280 (Part B) (1/01) 4 IMPOR\bAN\b:Attach to this Response any supportive documentary evidence (medical reports, affidavit and declaration, etc.) which establishes that there is not good cause for the Administrative \birector to grant the Petition for Change of Primary Treating Physician. (See Title 8, Califor\bia Code of Regulatio\bs, § 9786) VERIFICATION I declare under penalt\b of perjur\b under the laws of the State of California that the foregoing is true and correct. EXECUTE\b AT \r \r \r , CALIFORNIA ON \r \r (City) (\bate) BY: \r \r \r \r// \r \r \r Original Signature of Person Preparing the Respons e // Nam e of Person Preparing the Response (Print or type) Address: ________________________________________________________________ NOTICE TO EMPLOYEE/EMPLOYEE’S ATTORNEY : \bHE PROOF OF SERVICE BY MAIL DECLARA\bION BELOW MUS\b BE COMPLE\bED INDICA\bING A COPY OF \bHIS RESPONSE HAS BEEN MAILED \bO \bHE CLAIMS ADMINIS\bRA\bOR OR I\bS A\b\bORNEY, AND \bHE PRIMARY \bREA\bING PHYSICIAN. NOTICE TO PRIMARY TREATING PHYSICIAN : \bHE PROOF OF SERVICE BY MAIL DECLARA\bION BELOW MUS\b BE COMPLE\bED INDICA\bING A COPY OF \bHIS RESPONSE HAS BEEN MAILED \bO \bHE CLAIMS ADMINIS\bRA\bOR OR I\bS A\b\bORNEY, AND \bHE EMPLOYEE OR \bHE EMPLOYEE’S A\b\bORNEY. PROOF OF SERVICE BY MAIL On I served a copy of this Response to Petition for Change of Treating Physician on (date ) at \ and (Claims Administrator or its Attorney ) (address) at \ by (Primary Treating Physician or Employee/ \ (address) Employee's Attorney) placing a true copy enclosed in 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)