Election of Healthcare Provider for Workplace Injuries
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Note: This sample form is provided as a tool for employers. This form is general in nature, and may not be required by law. ManagEase is not a law firm. This form does not constitute legal advice, nor is any attorney-client relationship created or implied. Prior to using this form, we recommend that you consult with an attorney knowledgeable in any potentially applicable federal and/or state laws regarding the specific intended use of this form.
|Last Updated||February 8, 2023|
This form can be used by employees who to indicate that, in the event of an on-the-job injury, the employee would either (A) prefer to be treated by the Company's designated physician or (B) prefer to be treated by their own designated healthcare provider.
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|NHF10012.2 Election of Healthcare Provider for Workplace Injuries.pdf|
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