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FORM B - Employee Request for Medical Treatment <br /> Print Form <br /> •°*eras+''� <br /> SAN JOAQUIN COUNTY <br /> EMPLOYEE REQUEST for MEDICAL TREATMENT <br /> TO: Doctor <br /> Doctor's Address <br /> while in our employ <br /> (Employee) <br /> is requesting medical treatment for incident occurring <br /> (Date) (Time) <br /> A Workers'Compensation claim has been filed.Please complete and send the"Doctor's First Report of Work <br /> Injury"to San Joaquin County Human Resources,Risk Management,44 N.San Joaquin Street,Suite 330, <br /> Stockton CA 95202. <br /> FROM:EMPLOYER San Joaquin County <br /> DEPARTMENT: <br /> ADDRESS: 44 N.San Joaquin Street,Suite 330,Stockton CA 95202 <br /> BY: <br /> (Supervisor) (Date) <br /> OR: N have declined the offer of professional medical treatment at this time" <br /> (Employee's Signature) (Date) <br /> Distribution: Original.................................Doctor <br /> AT 2012/99) Yellow..............Human Resources <br /> Updates Address Revision 9/09 Pink.......................................Retain <br /> San Joaquin County <br /> Department of Public Works <br /> County of San Joaquin Dept of Public Works IIPP Rev 2020-01-31.docx P a g e 23 <br />