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HOME OFFICE <br />SAN FRANCISCO <br />ALL EFFECTIVE DATES ARE <br />AT 12:01 AM PACIFIC <br />STANDARD TIME OR THE <br />TIME INDICATED AT <br />PACIFIC STANDARD TIME <br />ENDORSEMENT AGREEMENT <br />MEDICAL PROVIDER NETWORK <br />EFFECTIVE JULY 1, 2015 AT 12.01 A.M. <br />FRIENDS OF SANTA ANA ZOO <br />1801 E CHESTNUT AVE <br />SANTA ANA, CA 92701 <br />CONTINUED. <br />9048875-15 <br />RENEWAL <br />SP <br />3-68-03-58 <br />PAGE 2 OF <br />TO BE TREATED BY A PHYSICIAN OF HIS OR HER CHOICE FROM <br />WITHIN THE MEDICAL PROVIDER NETWORK AFTER THE FIRST VISIT, <br />THE POLICYHOLDER SHALL NOTIFY EMPLOYEE OF THE METHOD BY <br />WHICH THE LIST OF PARTICIPATING PROVIDERS MAY BE ACCESSED <br />BY EMPLOYEES, <br />IT IS FURTHER AGREED THAT IF AN INJURED EMPLOYEE DISPUTES <br />EITHER THE DIAGNOSIS OR THE TREATMENT PRESCRIBED BY THE <br />TREATING PHYSICIAN, THE EMPLOYEE MAY SEEK THE OPINION OF <br />- ANOTHER PHYSICIAN WITHIN THE MEDICAL PROVIDER NETWORK. IF <br />THE INJURED EMPLOYEE DISPUTES THE DIAGNOSIS OR TREATMENT <br />PRESCRIBED BY THE SECOND PHYSICIAN, THE EMPLOYEE MAY SEEK <br />THE OPINION OF A THIRD PHYSICIAN WITHIN THE MEDICAL <br />PROVIDER NETWORK, <br />IT IS FURTHER AGREED THAT THIS ENDORSEMENT IN NO WAY <br />AFFECTS THE RIGHTS OF AN INJURED WORKER TO PREDESIGNATE A <br />PHYSICIAN. AN EMPLOYEE MUST FILE WRITTEN NOTICE OF THE <br />PREDESIGNATION WITH THE EMPLOYER PRIOR TO THE DATE OF <br />INJURY. THE NOTICE MUST INCLUDE THE PHYSICIAN'S SIGNATURE <br />OF AGREEMENT TO THE PREDESIGNATION, AND THE FOLLOWING <br />CONDITIONS MUST APPLY; <br />THE PHYSICIAN IS THE EMPLOYEE'S REGULAR PHYSICIAN, , <br />THE PHYSICIAN IS THE EMPLOYEE'S PRIMARY CARE PROVIDER WHO <br />HAS PREVIOUSLY DIRECTED THE MEDICAL TREATMENT OF THE <br />CONTqog <br />3 <br />NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE G\}.�' <br />OR EXTEND ANY OF THE TERMS, <br />TATIONS OF <br />POLICY OTHER THAN AS STATED, CONOTH NG ELSEWHERE TSINO THIS (POLICY SHALTHIS "ON \ .,}P� <br />HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGHEEM S OR Q9 - <br />LIMITATIONS OF THIS ENDORSEMENT. <br />COUNTERSIGNED AND ISSUED AT SAN FRANCISCO., <br />//�GlJG'C� <br />AUTHORIZED REPRESEN��Cf<Vf1VE <br />SCIF FORM 10277 (REV.7.2014) <br />JUNE 26, 2015 <br />PRESIDENT AND CEO <br />2437 <br />OLD DP 217 <br />