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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. NOTE: If your date of injury is January 1, 2004, or later, a chiropractor cannot be your treating physician after you have received 24 chiropractic visits unless your employer has authorized additional visits in writing. The term "chiropractic visit" means any chiropractic office visit, regardless of whether the services performed involve chiropractic manipulation or are limited to evaluation and management. Once you have received 24 chiropractic visits, if you still require medical treatment, you will have to select a new physician who is not a chiropractor. This prohibition shall not apply to visits for postsurgical physical medicine visits prescribed by the surgeon, or physician designated by the surgeon, under the postsurgical component of the Division of Workers' Compensation's Medical Treatment Utilization Schedule. 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 Title 8, California Code of Regulations, section 9783.1 (Optional DWC Form 9783.1 Effective date July 1, 2014) Predesignation of Personal Physician; Reporting Duties of the Primary Treating Physician Regulations 8 C.C.R. section 9780, et seq. (Approved 02/12/2014) W04NE116 travefers.com w..rFt RfdrManalfuntmtDivis[mt The Travelers IndemnityCompany and its property casual affiliates. One Tower Square, Hartford, CT 06183 Remois<APPRWmBr: P Y P P Y casualty q © 2016 The Travelers Indemnity Company. All rights reserved. Travelers and the Travelers Umbrella logo are regi Travelers Indemnity Company in the U.S. and other countries. CE-10277 Rev. 10-2015 Risk Management Anatyst