EMPLOYEE DESIGNATION OF PERSONAL PHYSICIAN

All authorized medical expenses are fully covered following an injury at work. If you need immediate medical care, you will be referred by the City of San Bruno to a local doctor designated by the City of San Bruno. If you wish to change doctors, please contact the Personnel Office. Should you continue to require treatment 30 days after reporting your at-work injury, you may be treated by a physician of your own choice.

You may also be treated by your own personal physician (the physician who has previously directed your medical treatment, and currently retains your medical records) immediately following your at-work injury by completing this form. This form must be on file in the Personnel Department prior to an at-work injury having occurred, otherwise such treatment will be considered self-procured.

_____________________________________________________
  Name of Primary Physician


_____________________________________________________
  Address


_____________________________________________________
  Telephone number

_____________________________         Employee's Printed Name	____________________________  Employee's Signature
_____________________ Date	____________________________  Employee's Department

NOTE: Employees not choosing to designate a personal physician prior to their industrial injury will receive initial treatment from a City-appointed physician or medical group (for at least the first 30 days after the injury is reported). If you have a form on file and you subsequently change primary doctors, you must complete a new form immediately. If you have any questions, contact the City of San Bruno Personnel Department at (650)616-7055.