HCO Enrollment Form Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
HCO Enrollment Form. This is a California form and can be use in General Workers Comp.
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Tags: HCO Enrollment Form, WC-HCO1, California Workers Comp, General
HCO Enrollment Form
I have received information about these Health Care
Organizations [Employer to insert names of HCOs offered]
A.
B.
C.
D.
I want to enroll in an HCO for my medical care for any work-related injury or
illness.
(Write in the name of the HCO you have chosen)
The physician who treats me for non-work injuries,
, is in one of the HCOs listed above:
(name of physician)
(name of HCO, if different than the HCO you have chosen above)
I do not want to enroll in an HCO and want to choose my personal physician or
chiropractor for any work-related injury or illness.
Name of Employee
Signature
Date
If you have chosen an HCO above, please fill in this box:
Date of Birth
Sex M
Race/:
Social Security Number
F
Occupation
White
Latino
Other (specify)
The language you feel most comfortable speaking:
English
Spanish
Chinese
Black
Asian or Pacific Islander
Tagalog
Other:
(specify)
WC-HCO1
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