HomeMy WebLinkAbout106.022 - FC-19, Employee Physician Pre-Designation Form
ADMINISTRATIVE MANUAL
FORMS
106.022 EMPLOYEE PHYSICIAN PRE-DESIGNATION
FORM (FC-19)
EFFECTIVE: AUGUST 2009
Current Revision Date: 04/26/21 Next Revision Date: 04/26/24
Author’s Name/Rank: Bradley Dandridge, Battalion Chief Review Level: 1
Administrative Support:
Evelyn Yin-Zepeda,
Management Analyst II
PURPOSE
This policy ensures proper documentation of all injuries sustained during the course
of employment with the City of Fresno (City) Fire Department (FFD or Department).
APPLICATION
This form notifies the City of Fresno’s Risk Management Division of the name and
address of the physician a member desires to consult when an on-the-job injury (OJI),
job related illness, or exposure occurs.
OPERATIONAL POLICY
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OPERATIONAL GUIDELINE
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PROCESS
It is the responsibility of the individual member to ensure a completed FC-19 is on file
with the Safety and Wellness Officer and City of Fresno’s Risk Management Division
prior to an On-the-Job-Injury (OJI).
A physician’s signature must be on file prior to seeking treatment for an (OJI) illness
or injury of the member.
Section 106.022
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INFORMATION
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DEFINITIONS
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CROSS-REFERENCES
Administrative Manual
Section 110.003, On-the-Job Injury (OJI) Reporting.
Section 106.022
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FC-19
CITY OF FRESNO MEDICAL PROVIDER NETWORK (MPN)
Employee Physician Pre-Designation Form
If I am injured on the job, I request to be treated by my personal physician, who has treated me before and has my medical
treatment records.
(Employer Name)
Employee Information:
(Employee’s Name – Please PRINT)
(Employee’s Date of Birth)
(Department/Division)
(Employee’s Date of Hire)
I understand that my physician must agree to act as my Primary Treating Provider under my employer’s workers’
compensation program for my work-related injury. In the event the below-named physician is not appropriate to treat my
work-related injury or does not agree to act in this capacity, I will be required to seek care with an MPN physician.
I agree to the above conditions and will return the completed form to my employer.
(Employee’s Signature)
Your Doctor’s Information:
(Doctor’s Name – Please PRINT)
(Doctor’s Specialty)
(Date)
(Doctor’s Federal Tax ID Number)
(Doctor’s Telephone Number)
(Doctor’s Address)
I hereby certify I am the above-named employee’s regular physician, licensed pursuant to Chapter 5 (commencing with
Section 2000) of Division 2 of the Business and Professions Code. I have personally directed the medical treatment of
this employee, and I retain this employee’s medical records, including his or her medical history. I agree to be pre-
designated as this employee’s physician in the event of an industrial injury or illness.
(Doctor’s Signature) (Date)
(Note to Employer: Retain the completed form in employee’s personnel file and forward a copy to the TMC MPN
Coordinator.)
For questions about the City of Fresno MPN, please contact the Risk Management Division at 621-6903, contact the MPN Call
Center at 866-536-2853.
Section 106.022
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