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For Use Beginning August 23, 1996
The Workers’ Compensation Act
is designed to provide reimbursement for reasonable medical care for
someone who suffers an injury arising in the course of his employment and
causally related thereto. Pursuant to the Act, your employer will provide
payment for reasonable surgical and medical services, services rendered by
physicians or other health care providers, medicines and supplies, as and
when needed.
If you require emergency
medical treatment, you may seek it from any provider, however, any
subsequent non-emergency treatment shall be obtained from one of the
designated health care providers whose names appear on the list posted on
your employer’s premises. You must obtain treatment from one of these
providers for ninety (90) days from the date of your first visit to that
provider; otherwise, your employer shall not be responsible for payment of
your non-emergency medical bills for that first ninety (90) days.
During the initial ninety
(90) days from the date of your first visit, you have the right to switch
from one health care provider on the list to another and that treatment
will be paid for by your employer.
If a designated health care
provider refers you for treatment to another health care provider whose
name is not on the list, your employer will pay for treatment rendered by
the provider whom you were referred.
Naturally, you have the right
to seek treatment or medical consultation from a non-designated health
care provider during the initial ninety (90) day period following the
first visit, but you are personally responsible for payment for those
services.
You have the right to seek
treatment from any health care provider at the expiration of the ninety
(90) day period from the date of first visit. This treatment will be paid
for by your employer unless the treatment is found to be unreasonable or
unnecessary by a utilization review organization pursuant to the
utilization review process contained in the Pennsylvania Workers’
Compensation Act.
Your employer will be
responsible for the cost of that treatment after the initial ninety (90)
day period has ended but only if you notify the employer that you are
receiving treatment from a non-designated health care provider and only if
that notice is provided to your employer within five (5) days after the
first visit to that provider. If you provide notice to your employer of
treatment by a non-designated provider more that five (5) days after the
first visit to that provider, the employer will not be responsible to pay
for treatment rendered by that non-designated provider until it receives
notification from you that you are receiving such treatment.
Should invasive surgery be
prescribed by a designated health care provider, your employer will pay
for an additional opinion from a health care provider of your choice. If
the additional opinion differs from the opinion of the designated health
care provider and if the additional opinion provides a specific and
detailed course of treatment, you will then determine which course of
treatment to follow. If you choose to follow the procedures recommended in
the additional opinion, your employer will pay to have such procedures
performed by one of its designated health care providers and will not be
responsible for payment for treatment provided by a non-designated
provider for a period of ninety (90) days from the date of your visit to
the health care provider from whom you obtained the additional opinion.
I HEREBY ACKNOWLEDGE THAT I
HAVE BEEN INFORMED OF AND UNDERSTAND MY RIGHTS AND DUTIES UNDER THE
WORKER’S COMPENSATION ACT AS SET FORTH HEREIN.
DATE:
___________________
___________________________
Employee
EMPLOYEE RE-NOTIFICATION
I hereby acknowledge that I
have been informed again and that I understand my rights and duties under
the Worker’s Compensation Act. I have received a copy of this Worker’s
Compensation employee notification form.
DATE:
___________________
___________________________
Employee
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