PREDESIGNATION OF ACUPUNCTURIST Labor Code 4601 (a) If the employee so requests, the employer shall tender the employee one change of physician. The employee at any time request that the employer tender this one-time change of physician. Upon request of the employee for a change of physician, the maximum amount of time permitted by law for the employer or insurance carrier to provide the employee an alternative physician or, if requested by the employee, a chiropractor, or an acupuncturist, shall be five working days from the date of the request. Notwithstanding the 30-day time period specified in Section 4600, a request for a change of physician pursuant to this section may be made at any time. The employee is entitled, in any serious case, upon request, to the services of a consulting physician, chiropractor, or acupuncturist of his or her choice at the expense of the employer. The treatment shall be at the expense of the employer. (c) If an employee requesting a change of physician pursuant to subdivision (a) has notified his or her employer in writing prior to the date of injury that he or she has a personal acupuncturist, the alternative physician tendered by the employer to the employee, if the employee so requests, shall be the employee's personal acupuncturists. For the purpose of this article, "personal acupuncturist" means the employee's regular acupuncturist licensed pursuant to Chapter 12 (commencing with Section 4935) of Division 2 of the Business and Professions Code, who has previously directed treatment of the employee, and who retains the employee's acupuncture treatment records, including his or her acupuncture history. ------ ------- ------ ------- ------- ------- --------- ------ ----- -- -------- Cut at perforation above and turn in to YOUR Human resources/Personnel Dept Employee Designation of Personal Acupuncturist Employer: _____________________________________________________________ Attention: Human Resources/Personnel Dept. Employee: _____________________________________________________________ This notice serves that if, during the course of employment, I experience an industrial injury, I hereby request to be examined and/ or treated by my personal acupuncturist as designated below: I, ________________________ , hereby designate Dr. Khanh M. Lam, O.M.D., L.Ac., located at 7151 Lincoln Avenue # K; Buena Park, CA 90620, to be my "Personal Acupuncturist" pursuant to Labor code 4601. Employee Signature: ___________________________ Date: ______________________ View other news

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