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Chapter 4.5. Division of Workers' Compensation

Subchapter 1. Administrative Director--Administrative Rules

Article 3.6. Independent Medical Review

New query

§9768.5. Physician Contract Application Form

Physician application contract DWC form 9768.5 (pdf)

Note to physicians: please use three letter specialty code when completing block 3 of application form)
SPECIALTY CODES
MAI Allergy and Immunology
MAA Anesthesiology
MRS Colon & Rectal Surgery
MDE Dermatology
MEM Emergency Medicine
MFP Family Practice
MPM General Preventive Medicine
MOSU Hand - Orthopaedic Surgery, Plastic Surgery, General Surgery
MMM Internal Medicine
MMV Internal Medicine - Cardiovascular Disease
MME Internal Medicine - Endocrinology Diabetes and Metabolism
MMG Internal Medicine - Gastroenterology
MMH Internal Medicine - Hematology
MMI Internal Medicine - Infectious Disease
MMO Internal Medicine - Medical Oncology
MMN Internal Medicine - Nephrology
MMP Internal Medicine - Pulmonary Disease
MMR Internal Medicine - Rheumatology
MPN Neurology
MNS Neurological Surgery
MNM Nuclear Medicine
MOG Obstetrics and Gynecology
MPO Occupational Medicine
MOP Opthalmology
MOSG Orthopaedic Surgery (General)
MOSS Orthopaedic - Shoulder
MOSK Orthopaedic - Knee
MOSB Orthopaedic - Spine
MOSF Orthopaedic - Foot and ankle
MTO Otolaryngology
MAP Pain Management - Psychiatry and Neurology, Physical Medicine and Rehabilitation, Anesthesiology
MHA Pathology
MEP Pediatrics
MPR Physical Medicine & Rehabilitation
MPS Plastic Surgery
MPD Psychiatry
MSY Surgery
MSG Surgery - General Vascular
MTS Thoracic Surgery
MTO Toxicology - Preventive Medicine, Pediatrics, Emergency
MUU Urology
MRD Radiology
POD Podiatry
DWC Form 9768.5 11/2006


Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Section 4616.4, Labor Code.Authority cited: Sections 133 and 4616, Labor Code. Reference: Section 4616.4, Labor Code.

HISTORY

1. New section filed 12-31-2004 as an emergency; operative 1-1-2005 (Register 2004, No. 53). A Certificate of Compliance must be transmitted to OAL by 5-2-2005 or emergency language will be repealed by operation of law on the following day.

2. Certificate of Compliance as to 12-31-2004 order, including amendment of section, transmitted to OAL 4-29-2005 and filed 6-10-2005 (Register 2005, No. 23).

3. Change without regulatory effect amending form filed 10-18-2006 pursuant to section 100, title 1, California Code of Regulations (Register 2006, No.42).

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