Worker's Comp Acknowledgement and Designated Physician

Due Date: First Day of Class

While working in the hospital and on the ambulance as part of this course you are covered by COC's Worker's Compensation Program.  That means if you get hurt during a clinical shift, COC will send you to a Worker's Compensation doctor and treat you for free, and cover your bills if you are treated in an emergency room. You can choose to be treated by your own doctor at your expense instead, but they must agree to it in advance by signing page 2 of the Designated Physician form. This must be done by Week 1 of the course.

• Step 1

  • DO NOT PRINT this packet! ONLY PRINT the forms below in Step 2.
  • Read the Worker's Compensation Packet Download Worker's Compensation Packet
    very carefully. It explains what to do if you get hurt while off-campus for clinical shifts, and what will happen afterwards. 

• Step 2

• The forms do not download correctly from most phones. Students can access computers for free at the Valencia TLC Links to an external site. and Library Links to an external site. and the Canyon Country Library and Learning Center Links to an external site. in the Student Services Building. Students who have paid the Student Support Fee can print documents for free (worth up to $16/month ) through the Wepa app.
  
  • Download and save the Prime Advantage Acknowledgement Form Download Prime Advantage Acknowledgement Form
  • Open the saved file and type your information in the yellow boxes
  • Print and sign the form and use a paperclip to attach it to Checklist 1 in the order shown on the checklist

• Step 3

  • Download and save the Pre-Designation of Personal Physician Download Pre-Designation of Personal Physician
  • If you are injured during EMT class, you are covered by COC's Worker's Compensation program
  • Everyone must fill out page one of the form
    • If you want to be treated by COC's Worker's Compensation doctors, you are finished with the form after page one - print it and add it to the checklist
  • If you want your personal Worker's Compensation doctor to treat you:
    • • Fill out page 2 of the form
      • Take it your doctor to sign - they need to prove they are certified for Worker's Compensation cases
      • This must be done by Week 1
  • Print the form and use a paperclip to attach it to Checklist 1 in the order shown on the checklist