TO:______________________________________________

FROM:___________________________________________

DATE:____________________________________________

This notice is to advise you that I am selecting the following physician as my primary treating physician who is to direct and/or provide all medical treatment to me in the event that I am ever injured in the course and scope of my employment.

PRIMARY TREATING PHYSICIAN:_____________________________

ADDRESS:_________________________________________

TELEPHONE #:_____________________________________

SIGNED:__________________________________________

SOC. SEC.#:________________________________________

Instructions: Print and complete this form. Present the original of this document to your employer and keep a photocopy for your records.