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Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 5. Predesignation of Personal Physician; Request for Change of Physician; Reporting Duties of the Primary Treating Physician; Petition for Change of Primary Treating Physician

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§9783. DWC Form 9783.1 Notice of Personal Chiropractor or Personal Acupuncturist


If your employer or your employer's insurer does not have a Medical Provider Network, you may be able to change your treating physician to your personal chiropractor or acupuncturist following a work-related injury or illness. In order to be eligible to make this change, you must give your employer the name and business address of a personal chiropractor or acupuncturist in writing prior to the injury or illness. Your claims administrator generally has the right to select your treating physician within the first 30 days after your employer knows of your injury or illness. After your claims administrator has initiated your treatment with another doctor during this period, you may then, upon request, have your treatment transferred to your personal chiropractor or acupuncturist.

You may use this form to notify your employer of your personal chiropractor or acupuncturist.

Your Chiropractor or Acupuncturist's Information:


(name of chiropractor or acupuncturist)


(street address, city, state, zip code)


(telephone number)

Employee Name (please print):


Employee's Address:


Employee's Signature _______________ Date: ___

Title 8, California Code of Regulations, section 9783.1. (DWC Form 9783.1- Effective date March 2006)

Note: Authority cited: Sections 133, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600 and 4601, Labor Code.


1. New section filed 3-14-2006; operative 3-14-2006 pursuant to GovernmentCode section 11343.4 (Register 2006, No. 11).

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