Cal. Code Regs. tit. 10 § 2592.14
POST-DESIGNATION TRAINING FORM
______________________________
(Adjuster's or Medical Bill Reviewer's Name)
[] Claims Adjuster [] Medical-Only Claims Adjuster [] Medical Bill Reviewer
(Check Only One)
has successfully completed the post-designation workers' compensation training and hours noted below pursuant to California Insurance Code Section 11761 and California Code of Regulations, Title 10, Sections 2592.02, 2592.03, 2592.04, and 2592.05
Name and Topic of Post-Designation Training Taken:
______________________________
Total Hours of Post-Designation Training Completed: ____________
Date of Post-Designation Training: _______________
Post-Designation Training Verified By:
______________________________
(Name of Insurer or Medical Billing Entity)
| ___________________________ | ___________________________ | |
| (Date) | (Signature) |
Name of person awarding designation (print or type):
Title of person awarding designation:
Business address:
Cal. Code Regs. Tit. 10, § 2592.14
Note: Authority cited: Section 11761, Insurance Code. Reference: Section 11761, Insurance Code.