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 2002 © American LegalNet, Inc.