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HOME OFFICE <br />SAN FRANCISCO <br />ALL EFFECTIVE DATESARE <br />AT 1401 AM PACIFIC <br />STANDARD TIME OR THE <br />TIME INDICATED AT <br />PACIFIC STANDARD TIME <br />ENDORSEMENT AGREEMENT' <br />MEDICAL PROVIDER NETWORK <br />EFFECTIVE JUNE 160 2015 AT 12.01A.M. <br />BIG RED BUS <br />6400 E PACIFIC COAST HWY <br />LONG BEACH, CA 90803 <br />CONTINUED. <br />9102788-15 <br />RENEWAL <br />Sc <br />PAGE 2 OF 3 <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, I'HE 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 />IIIII�Iii[l[IINII <br />NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD....TO VARY, ALTER, WAIVE <br />OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, '.OR LIMITATIONS OF THIS <br />POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE <br />HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR <br />LIMITATIONS OF THIS ENDORSEMENT. <br />COUNTERSIGNED AND <br />S/ISSUED <br />.,tAATSAN FRANCISCO: MAY 6, 2015 <br />AUTHORI"LED REPRESENT' IVE PRESIDENT AND CEO <br />SCIF FORM 10217 (REV.7�2014) <br />2437 <br />OLD OP 217 <br />