Susan Mckinney

 
 CASA COLINA 
 Hospital and Centers for Healthcare 
 PERSONAL PHYSICIAN PREDESIGNATION FORM 
 I, the undersigned employee, in case of an industrial injury or illness, elect to receive medical 
 treatment from my personal physician. 
 I understand that Labor Code Section 4600 defines my "personal physician" as my "regular 
 physician and surgedn" who has previously directed my medical treatment and who retains my 
 medical records, including medical history. 
 Nicole Price
 Employee Name: 
 Department: 
 Imaging 
 Elm 
 Date: 
 18/20/05
 Employee Signature: 
 Check one: 
 do not choose to designate a personal physician 
 do choose to designate a personal physician, see below 
 
 S:/Human Resources/FormsPersonalPhysicianPredesignationForm
