DWC FORM 9783.1 (March 14, 2006)
NOTICE OF PERSONAL CHIROPRACTOR OR PERSONAL ACUPUNCTURIST
If your employer or your employer’s insurer does not have a Medical Provider Network, you
may be able to change your treating physician to your personal chiropractor or acupuncturist
following a work-related injury or illness. In order to be eligible to make this change, you must
give your employer the name and business address of a personal chiropractor or acupuncturist in
writing prior to the injury or illness. Your claims administrator generally has the right to select
your treating physician within the first 30 days after your employer knows of your injury or
illness. After your claims administrator has initiated your treatment with another doctor during
this period, you may then, upon request, have your treatment transferred to your personal
chiropractor or acupuncturist.
You may use this form to notify your employer of your personal chiropractor or acupuncturist.
Your Chiropractor or Acupuncturist’s Information:
(name of chiropractor or acupuncturist)
(street address, city, state, zip code)
Employee Name (please print):