Designated Medical Provider Selection Employer Designation

Please complete a separate form for each business location.

All fields marked * + are required fields

Employer Details

Legal Name^*

Address

City

State

Zip Code

Phone

Contact First Name^*

Contact Last Name^*

Contact Title

Contact Email Address^*

Has the medical provider been informed of your selection?^*

Yes

If no, WSI will not recognize your selection

Designated medical provider(s)^*

Provider Name⁺

Address⁺

City⁺

State⁺

Zip Code⁺

Phone⁺

Contact First Name⁺

Contact Last Name⁺

Contact Email Address⁺

Please Note:

Designated Medical Provider (DMP) selection should be reviewed annually.
The DMP selection does not apply to emergency care.
Employees have the right to add additional medical providers to the above list (referred to as opting out).
Employees must notify the employer of their additional medical provider or opting out prior to an injury.
There can be more than one DMP. DMPs can be individuals, clinics, hospitals or any combination.
They can be medical doctors, chiropractors, osteopaths, dentists, optometrists or any combination.
The DMP will remain in effect until the employer notifies WSI of changes.
If an employee opts out, he/she should retain a copy of the form.

Acknowledgment & Signature

Signature^*

Check Box to Sign^*