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ENDORSEMENT AGREEMENT <br />HOME OFFICE <br />SAN FRANCISCO <br />ALL EFFECTIVE DATES ARE <br />AT 12:01 AM PACIFIC <br />STANDARD TIME OR THE <br />TIME INDICATED AT <br />PACIFIC STANDARD TIME <br />MEDICAL PROVIDER NETWORK <br />EFFECTIVE JULY 1, 2021 AT 12.01 A.M. <br />FRIENDS OF SANTA ANA ZOO <br />1801 E CHESTNUT AVE <br />SANTA ANA, CA 92701 <br />CONTINUED. <br />REP D1 <br />9048876-21 <br />RENEWAL <br />SP <br />3-68-03-58 <br />PAGE 2 OF <br />TO BE TREATED BY A PHYSICIAN OF HIS OR HER CHOICE FROM <br />WITHIN THE MEDICAL PROVIDER NETWORK AFTER THE FIRST VISIT. <br />THE POLICYHOLDER SHALL NOTIFY EMPLOYEE OF THE METHOD BY <br />WHICH THE LIST OF PARTICIPATING PROVIDERS MAY BE ACCESSED <br />BY EMPLOYEES. <br />IT IS FURTHER AGREED THAT IF AN INJURED EMPLOYEE DISPUTES <br />EITHER THE DIAGNOSIS OR THE TREATMENT PRESCRIBED BY THE <br />TREATING PHYSICIAN, THE EMPLOYEE MAY SEEK THE OPINION OF <br />ANOTHER PHYSICIAN WITHIN THE MEDICAL PROVIDER NETWORK. IF <br />THE INJURED EMPLOYEE DISPUTES THE DIAGNOSIS OR TREATMENT <br />PRESCRIBED BY THE SECOND PHYSICIAN, THE EMPLOYEE MAY SEEK <br />THE OPINION OF A THIRD PHYSICIAN WITHIN THE MEDICAL <br />PROVIDER NETWORK. <br />IT IS FURTHER AGREED THAT THIS ENDORSEMENT IN NO WAY <br />AFFECTS THE RIGHTS OF AN INJURED WORKER TO PREDESIGNATE A <br />PHYSICIAN. AN EMPLOYEE MUST FILE WRITTEN NOTICE OF THE <br />PREDESIGNATION WITH THE EMPLOYER PRIOR TO THE DATE OF <br />INJURY. THE NOTICE MUST INCLUDE THE PHYSICIAN'S SIGNATURE <br />OF AGREEMENT TO THE PREDESIGNATION, AND THE FOLLOWING <br />CONDITIONS MUST APPLY: <br />THE PHYSICIAN IS THE EMPLOYEE'S REGULAR PHYSICIAN. <br />THE PHYSICIAN IS THE EMPLOYEE'S PRIMARY CARE PROVIDER WHO <br />HAS PREVIOUSLY DIRECTED THE MEDICAL TREATMENT OF THE <br />CONTINUED <br />NOTHING IN THIS ENDORSEMENT SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND <br />ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY <br />OTHER THAN AS ABOVE STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE <br />HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR <br />LIMITATIONS IN THIS ENDORSEMENT. <br />COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: <br />;e D� / <br />2437 <br />AUTHORIZED REPRESENT IVE <br />SCIF FORM 10217 (REV.4-2018) <br />JUNE 25, 2021 <br />PRESIDENT AND <br />3 <br />�oRaN <br />o Y <br />a <br />RiskMmWmentDMsian <br />REVIEWED & APPROVED BY: <br />/y <br />I �f R. Y� <br />Risk Management Analyst <br />