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:

Note: Authority cited: Section 11761, Insurance Code. Reference: Section 11761, Insurance Code.

History

1. New section filed 1-23-2006; operative 2-22-2006 (Register 2006, No. 4).