Once the "Member Information" section is completed and signed, scan or take a photo of the form, and email it to the address below. Keep a copy for your records. Give the original form to your supervisor to route through proper Bureau channels.
Take the purple packet containing the Attending Physician's Report and Work Status Report to the doctor to complete and submit to FPDR. You may receive medical treatment from your primary care physician or a health care provider of your choice who is within your private health plan network and who is a:
Medical doctor (MD)
Osteopathic doctor (DO)
Chiropractor (DC) for 30 days or 12 visits, whichever first occurs.
If you need to go to an emergency room or urgent care facility, you may be treated by a Nurse Practitioner for non-life-threatening injuries. This is allowed for the initial visit. Follow up care should be provided by a MD, DO, DPM or Chiropractor as outlined above.
FPDR and Moda Health have a Coordination of Benefits program for members who have personal health care benefits outside of the Kaiser Permanente system. FPDR will initiate access to the coordination of benefits program when available to reduce the time needed to obtain urgent diagnostics or other emergent care for work related injuries/illnesses.
The urgency of medical treatment is determined by the doctor or provider prescribing the care and is not directed by FPDR or its staff.
If you have questions, you may contact FPDR directly.