| Coalition of University Employees (CUE) | 2855 Telegraph Ave., Suite #302, Berkeley, CA 94705 Contact CUE (510) 845-2221 (phone), (510) 845-7444 (FAX) |
It is advisable to have on file a letter designating your personal physician. Here is a sample you can use. Some campuses have a special form to use. See: UC Berkeley; UC Davis; UCSF; UCSB; LBNL.
To: Department of (name your department here)
Personnel Administration (or whoever is responsible for personnel actions in your department)
From:
Re: Designation of Personal Physician
Let this memorandum serve as notice that I designate (name your personal physician here along with address and phone contact information) as my personal physician. In the event that I should incur any sort of injury in conjunction with a work related incident, I assert my right to be treated by this physician as well as any referrals to specialists as he/she deems fit.
This memorandum is to be placed in my personnel file upon receipt.
Signed:
Date: