Predesignation of Personal Physician Form – Cornerstone (California Only)

📝 form availability ⚠️ warning the form can only be sent if the client's lead card status is sold , binding , or bound this form is only available for clients located in california and whose carrier is cornerstone it is used to collect an employee's designated physician information prior to any workplace injury claims ℹ️ note the form can also be accessed from the client’s payroll card by navigating to the employee tab 📤 how to send the form the form must be sent manually to the employee from the client’s lead card navigate to the client’s lead card click on the enrollments tab select the employees section open the actions dropdown click predesignation of personal physician at the bottom of the menu once triggered, the system will send the form link via text message and email to the employee 📱 employee experience 1\ form access when the employee clicks on the “complete form” button, the form will open in their browser 2\ page 1 – employee information most fields will be prefilled based on the employee’s record the only required input is ➡️ personal health insurance provider – this is a required field and must be completed by the employee select next to proceed 3\ page 2 – primary physician details the employee must provide physician/medical group name type of provider (select one doctor of medicine (m d ) , doctor of osteopathic medicine (d o ) , or medical group ) clinic or hospital address – a dynamic dropdown will offer address suggestions as the employee types all fields on this page are required select next to continue 4\ page 3 – signature & acknowledgment the employee will first review the prefilled document after reviewing, a signature modal will appear for them to digitally sign and acknowledge the form 5\ confirmation page upon successful completion, the employee will see a “thank you” page confirming submission 📬 submission notification once the employee submits the form, a notification is automatically sent to the broker with the payroll department always cc'd to confirm completion and ensure proper recordkeeping 📌 notes this form is required for specific compliance needs for california based clients with cornerstone as their carrier all submissions are logged in the client’s lead card under documents for future reference