Written
notification to Staff Members
PA
Worker’s Compensation Act
Section
306(f.1)(l)(i)
This
notice is provided to you to ensure that you are informed of your rights and
duties under and pursuant to the terms of Section 306(f.1)(l)(i) of the
Amendments to the Pennsylvania Worker’s Compensation Act effective August 31,
1993 and amendments enacted under Senate Bill 801 dated June 24, 1996.
Signing
this notification is your written acknowledgment that you have been informed of
your rights and duties and that you understand them.
In the
event that you suffer an injury arising in the course of your employment and
related thereto, you as an employee are generally entitled to have your employer
provide payment for reasonable surgical and medical services, services rendered
by physicians and other health care providers, medicines and supplies, as and
when needed. However, the Worker’s Compensation Act provides that your
employer may establish a list of a least 6 designated health care providers,
which providers you are required to visit, unless referred elsewhere by a
designated health care provider or by your employer, for a period of 90 days
from the date of your first visit.
Your
employer has posted designated health care providers in the accounting office at
643 Penn Avenue, West Reading, PA. If you fail to visit the designated health
care providers, your employer will not be responsible for the payment of the
medical services provided to you during that 90 day period from the first visit.
After
the period extending for 90 days from the first visit, you may obtain treatment
from the health care provider of your choice; but if you visit a non-designated
health care provider, you must notify your employer within 5 days of the first
visit that you have done so or your employer will not be responsible for payment
for services rendered by your chosen health care provider, until such time as
you provide notification to your employer. If it is subsequently determined that
the treatment provided to you was unnecessary or the charges rendered were
unreasonable, your employer will be relieved from liability for the payment of
such services.
Any
medical care provider who treats you is required to file periodic reports with
your employer on a form prescribed by the Department of Labor and Industry. The
first report will be filed within 10 days of your commencing treatment and
subsequent reports will be filed at least once per month thereafter as long as
treatment continues. Your employer will not be responsible for payment of
charges for your treatment until your health care provider has filed a report.
Your
health care provider will be compensated in accordance with a schedule of
prevailing charges and your employer is responsible for payment unless relieved
of responsibility for payment as described herein. Your health care provider may
not bill you or your employer in excess of the prevailing fee.
You
are entitled to have your health care provider paid for services within 30 days
of receipt by your employer, or its insurer, of bills and supporting records
unless your employer, or it insurer, disputes the reasonableness or necessity of
the treatment provided.
Your
employer is not responsible for payment of medical expenses you incur unless the
bills relate to conditions caused by an injury which arose in the course of your
employment.
You
have the right to request a utilization review relative to reasonableness or
necessity of all treatment provided by a health care provider, whether that
treatment was provided in the past or will be provided in the future. The
employer or its insurer is responsible to pay the cost of the initial
utilization review.
If you
as an employee refuse reasonable services of health care providers, surgical,
medical and hospital services, treatment, medicines and supplies, you may
forfeit all rights to compensation for any injury or increase in your incapacity
shown to have resulted for such refusal.
I
certify that I have read and received a copy of the attached notification and I
have also received a copy of the designated health care providers list and that
I understand my rights and duties as described in these documents.
Employee
Signature: ____________________________________________
Employee
Printed Name:___________________________________________________________________
Date:
_______________________________________________________
Witness
Signature: _________________________________________________
Revised
8/26/1999
Chris TALARICO &
Associates, Inc.
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