►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,
during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which
document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ
an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):

Section 2. Employer or Authorized Representative Review and Verification

(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

In case of an emergency, please notify:

Personal Chiropractor or Acupuncturist Designation Form

DWC FORM 9783.1

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.

NOTE: If your date of injury is January 1, 2004 or later, a chiropractor cannot be your treating physician after you have received 24 chiropractic visits unless your employer has authorized additional visits in writing. The term "chiropractic visit" means any chiropractic office visit, regardless of whether the services performed involve chiropractic manipulation or are limited to evaluation and management. Once you have received 24 chiropractic visits, if you still require medical treatment, you will have to select a new physician who is not a chiropractor. This prohibition shall not apply to visits for postsurgical physical medicine visits prescribed by the surgeon, or physician designated by the surgeon, under the postsurgical component of the Division of Workers' Compensation's Medical Treatment Utilization Schedule.

You may use this form to notify your employer of your personal chiropractor or acupuncturist. 

Title 8, California Code of Regulations, section 9783.1. (Optional DWC Form 9783.1 Effective date July 1, 2014)

In the event you sustain an injury or illness related to your employment, you may be treated for such injury or illness by your personal medical doctor (M.D, doctor of osteopathic medicine (D.O or medical group if:

On the date of your work injury you have health care coverage for injuries or illnesses that are not work related;

The doctor is your regular physician, who shall be either a physician who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist, or family practitioner, and has previously directed your medical treatment, and retains your medical records;

Your "personal physician" may be a medical group if it is a single corporation or partnership composed of licensed doctors of medicine or osteopathy, which operates an integrated multispecialty medical group providing comprehensive medical services predominantly for nonoccupational illnesses and injuries;

Prior to the injury your doctor agrees to treat you for work injuries or illnesses;

Prior to the injury you provided your employer the following in writing: (1) notice that you want your personal doctor to treat you for a work-related injury or illness, and (2) your personal doctor's name and business address.

You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met.

NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN

If I have a work-related injury or illness, I choose to be treated by:

Name of Insurance Company, Plan, or Fund providing health coverage for nonoccupational injuries or illnesses

I, the undersigned employee, have received the following items from my employer:

(List uniforms, equipment or tools below, including approximate current value

If I quit my employment, I agree to return all of the above items by my final day of employment. If my employer terminates my employment, I agree to return all of the above items at the time my employment is terminated. I further agree to return any or all of the above items at any other time my employer so requests.

I acknowledge that all items listed above remain the sole property of my employer.

PICO CARE Pharmacy 6650 Rosemead Blvd. . Pico Rivera, CA 90660 562-364-7922

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.

I have received Pico Care Pharmacy's Employee handbook and have access to the document at anytime in the pharmacy.

I hereby authorize the below listed employee to enroll in our company sponsored direct deposit program and authorize Abacus Payroll Services, Inc to initiate the following enrollment based upon the information contained within this form. Fax this signed form to your payroll support representative. Please allow two days before your next processing day. A VOIDED CHECK and or a BANK SPEC SHEET must be sent along with this form.

I authorize my employer and Abacus Payroll Services to deposit my paycheck each payday into the account named above. This authority will remain in force until I have given written notice that I have terminated it or until my employer has notified me that this deposit service has been terminated. I understand that I must give advance notice to allow my instructions to be executed. If ever an incorrect or inaccurate amount should be entered into my account, I agree to advise my employer immediately and I authorize Abacus Payroll Services and my bank to make appropriate adjustments and/or reversal transactions as deemed appropriate. I have attached a copy of a voided check, unsigned with the word "VOID" written on the check and or bank "SPEC SHEET" for each account listed above. By signing below I accept the terms and conditions as stated above and understand setup will occur within the next 1-2 payroll cycles. In order to avoid delays, full and complete information is required.