UCSF Campus Pre-Designation of Personal Physician
You may pre-designate a personal physician authorized to provide medical treatment for you in the event of a work related industrial injury or illness.
Due to a change in regulations by the Department of Industrial Relations, UCSF can no longer accept or honor pre-designation forms that are not authorized by your designated physician.
The attached Pre-Designation of Personal Physician form must be completed by you and signed by the personal physician (or accompanied by appropriate documentation as outlined below) that you have elected to receive treatment from in the event of an industrial injury or illness.
If you wish to pre-designate your personal physician, please complete the following Pre-Designation form, obtain your physician’s signature and return to the Disability Management Services Unit. If you are unable to obtain a signature on the form, signed documentation is required from your personal physician on his/her letterhead and submitted with the Pre-designation of Personal Physician form.
Also attached is a Notice of Personal Chiropractor or Personal Acupuncturist form that does not require authorization and may be kept on file, however, the Pre-Designation of Personal Physician form may only be authorized by a medical doctor (M.D.) or doctor of osteopathic medicine (O.D.)
To pre-designate your personal physician, chiropractor, or acupuncturist, please complete the appropriate form or forms and send to:
UCSF Human Resources
Disability Management Services Unit
UCSF Box 0964
San Francisco, Ca 94143-0964
In the event of a work-related injury or illness and a signed Pre-Designation of Personal Physician form is not on file for you, you must seek medical treatment at Employee Health Services (EHS), 2380 Sutter Street, 3rd Floor, San Francisco, Ca 94115, (415) 885-7580 or St. Francis Memorial Health Center at SBC Park, 24 Willie Mays Plaza, San Francisco, Ca 94107, (415) 972-2249, during the first 30 days following an industrial injury or illness. In the event of an emergency, you may seek medical treatment at your nearest emergency room.
Thank you for your cooperation. If you have additional questions, please contact Disability Management Services.