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Predesignated Physicians Forms

Caltech provides medical treatment to employees who have accepted workers' compensation claims. However, employees have the right to name either a personal physician, personal chiropractor,  or personal acupuncturist, who will provide medical treatment in the event of a work-related injury.

If you wish to predesignate a personal physician, chiropractor, or acupuncturist, please contact the Disability & leave Administration Unit in Human Resources.

Please Note

  • If the forms are incomplete, if you fail to return the forms, or if your selected provider (physician, chiropractor, acupuncturist) does not meet the predesignation requirements, your request may be disapproved.

  • The predesignation forms must be on file in the Disability & Leave Administration Unit prior to an injury occurring.

If there are any questions, contact the Disability & Leave Administration Unit at (626) 395-4577 or (626) 395-8382.