Dwc form 9783-2026

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The document is a Personal Physician Designation Form (DWC FORM 9783) that allows employees to designate their personal medical doctor or medical group for treatment of work-related injuries or illnesses, provided certain conditions are met. It outlines the requirements for predesignation, including having group health coverage, prior treatment by the physician, and written notice to the employer.

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Click ‘Get Form’ to open the dwc form 9783 in the editor.
In the 'Employee' section, enter your employer's name in the designated field.
Fill in your chosen physician's name (M.D. or D.O.) or medical group in the next field.
Provide the complete address of your physician, including city, state, and zip code.
Enter your physician's telephone number for easy contact.
Print your name and address in the respective fields to confirm your identity.
Sign and date the form at the bottom to finalize your predesignation request.
If applicable, ensure that your physician or their designated employee signs and dates the form as well.

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